Repair of Aortic Valve, Large Periaortic Abscess, and LV-PA Fistula in a 5-Year-Old With Acute Bacterial Endocarditis

Originally presented as an STSA/CTSNet Surgical Motion Picture at the 2016 STSA Annual Meeting. 

Objectives: The patient is a 5-year-old who presented with acute right hemispheric stroke, aphasia, fevers, and hemodynamic instability. Blood cultures were positive for Streptococcus Viridans. Echocardiography confirmed a small aneurysm near the right and left coronary cusps with a shunt from the left ventricular outflow tract (LVOT) to the pulmonary artery (PA). The patient was given an initial course of antibiotics, which resulted in improved hemodynamics and clearing of the blood cultures, although there was continued tachycardia and respiratory difficulty. A repeat echo showed a rapidly enlarging aneurysm and increased LVOT to PA shunt.

Methods: The operation was performed on cardiopulmonary bypass (CPB) with moderate hypothermia and a single dose cardioplegia. At the inception of CPB, the LV was stented and the bilateral branch was occluded. The surgeons discovered part of the left coronary leaflet of the aortic valve was destroyed and the commissure between the left and right coronary leaflets was disintegrating. There was also a large hole in the LVOT, communicating to the main PA via a walled-off aneurysm between the aorta and PA. The video shows these findings, the repair of the aortic valve, unroofing of the aneurysm, and patch closure of holes in the LVOT and main PA.

Results: The patient had an uneventful postoperative course with extubation on the second postoperative day, and transfer to step-down unit on the third postoperative day. The patient was transferred to an outpatient rehab facility for stroke recovery and postoperative day nine. A repeat echo showed mild residual aortic insufficiency, no residual shunt, elimination of the aneurysm, and good ventricular function. At discharge, the patient had recovered some right side strength and some speech.

Conclusion: Rapid increase in size of a periaortic aneurysm despite clearing blood cultures is an indication for urgent surgery. Aortic valve repair is possible by preserving remaining valve tissue and conforming annulus to “fit.” The video also nicely demonstrates how a large disruption in the LVOT can be “walled off” by inflammatory tissue. Aortic insufficiency with LVOT-PA communication requires immediate LV venting and branch PA occlusion at inception of CPB.

Copyright 2016, used with permission from the Southern Thoracic Surgical Association. All rights reserved.