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J Thorac Cardiovasc Surg 2003;125:725-727
© 2003 The American Association for Thoracic Surgery
Brief Communications |
From the Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
Received for publication May 16, 2002. Accepted for publication June 13, 2002. Address for reprints: Marc R. Moon, MD, Division of Cardiothoracic Surgery, Washington University School of Medicine, 3108 Queeny Tower, No. 1 Barnes-Jewish Plaza, St Louis, MO 63110 (E-mail: moonm{at}msnotes.wustl.edu).
Surgical management of prosthetic valve endocarditis (PVE) remains a formidable challenge, especially for patients who continue intravenous drug use after successful initial treatment.
1,2 In an effort to reduce the rate of recurrent endocarditis, strategies including aortic valve repair and aortic root replacement with a homograft have been reported. 1,3 However, recurrent endocarditis of an aortic homograft represents a clinical problem without a well-established solution. This report details the treatment of a second recurrence of PVE in an intravenous drug user who had undergone homograft root replacement 11 months previously for endocarditis of an aortic valve bioprosthesis.
Clinical summary
A 43-year-old woman with diabetes mellitus and a 25-year history of intravenous drug use was seen in June 2000 with a history of fever, chills, and a cough for several weeks. Blood cultures revealed Streptococcus sanguis. Transthoracic echocardiography revealed severe aortic insufficiency and a large vegetation on the noncoronary cusp of the valve. The development of severe congestive heart failure necessitated aortic valve replacement. At the operation, the noncoronary cusp was completely destroyed but the annulus was spared, so a bioprosthetic valve was inserted. 4 After the operation the patient received 4 weeks of organism-specific antibiotic therapy and was discharged to a drug rehabilitation center.
Three months later (September 2000), she was seen with fever and chills after resumption of intravenous drug use. Transesophageal echocardiography demonstrated no vegetations or abscesses. Blood cultures revealed Staphylococcus aureus. Initially, the patient was treated with intravenous vancomycin; however, she refused to return to a drug rehabilitation center and was discharged against medical advice with an oral course of antibiotics.
Three months later (December 2000), she returned in severe congestive heart failure with a perivalvular leak and an extensive aortic root abscess that involved more than half of the annulus. Aortic root replacement was therefore performed with an aortic homograft. She did well postoperatively and agreed to go to an extended care facility for further antibiotic treatment.
Eleven months later (November 2001), she was seen again with fever and chills, again after resumption of intravenous drug use. Transesophageal echocardiography revealed a 1.5-cm vegetation on the left coronary cusp of her aortic homograft valve (Figure 1). Blood cultures revealed Streptococcus mitis. Despite 10 days of organism-specific antibiotic therapy, the vegetation enlarged, and the patient remained septic. At the operation, inspection of the valve revealed an irregular vegetation on the left coronary cusp without involvement of the other two leaflets, annulus, or neoaorta. The vegetation was completely excised with, a 2-mm rim of homograft valve tissue (Figure 2, A). A 2 x 1-cm crescent-shaped piece of bovine pericardium was used to reconstruct the left coronary cusp with 5-0 polypropylene suture in a running fashion (Figure 2, B). Intraoperative transesophageal echocardiography revealed trivial aortic insufficiency. The patient recovered well and was discharged to a rehabilitation center, where she received intravenous antibiotics. At 5 months after this latest episode, the patient remains symptom free, has not resumed intravenous drug use, and has trivial aortic insufficiency according to transthoracic echocardiography.
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PVE is a rare complication after valve replacement for noninfectious causes. 5 However, the risk of PVE of a valve that was originally placed because of endocarditis is at least 7-fold higher, approaching 10%. 1,6 For patients who resume intravenous drug use, the recurrence rate may exceed 40%. 2
Aortic valve repair has been used effectively but sparingly for treatment of native valve endocarditis. 3 For recurrent infections involving an aortic valve prosthesis with an extensive abscess, homograft root replacement is the procedure of choice. Homograft valves are associated with a diminished risk of early PVE, 1,6 although a recent meta-analysis revealed that the early protective resistance to recurrent infection does not persist in the long term. 6
For our patient with multiply recurrent PVE, the options were limited. Prosthetic homograft valve repair was chosen, and although the durability of such a repair is entirely unknown, it afforded the patient with an opportunity for her infection to clear. If the patient can avoid intravenous drug use, a more permanent solution can be offered at a later date should the valve fail. To the best of our knowledge, valve repair of an aortic homograft has not been reported previously, but the application of this technique, in lieu of reoperative homograft root replacement, greatly reduced both the ischemic time and complexity of the operation. This probably contributed to the successful outcome to date. We therefore believe that valve repair should be considered for patients with active homograft endocarditis if anatomically feasible.
References
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