An 8-year-old male (24 kg) presented with intermittent fever for 45 days. Echocardiography demonstrated infective endocarditis of a bicuspid aortic valve with multiple vegetations (largest 8 × 6 mm), severe aortic stenosis (mean gradient 60 mmHg), mild aortic regurgitation, and a 7 × 6 mm aortic root abscess. Computed tomography (CT) showed extensive destructive infective endocarditis with multiple aortic root and ascending aortic pseudoaneurysms, right coronary ostial involvement, and splenic infarcts. Blood cultures were positive for Enterococcus species. Following one week of antibiotic therapy, urgent surgery was performed because of enlarging abscess cavities.
Operative Steps
A median sternotomy was performed, and cardiopulmonary bypass was established. A transverse aortotomy was carried out, followed by the complete excision of the infected bicuspid aortic valve. Radical debridement and exteriorization of the aortic root abscess cavities were achieved. The pulmonary autograft was harvested. The Ross procedure was performed with coronary button harvest and reimplantation. The right ventricular outflow tract was reconstructed using a 22 mm polytetrafluoroethylene (PTFE) valved conduit. Finally, the patient was weaned from cardiopulmonary bypass, and the incision was closed in a routine closure.
Preference Card
- Del Nido cardioplegia
- Pulmonary autograft
- 22 mm PTFE valved conduit
- Autologous pericardial patch
Tips and Pitfalls
It is essential to perform complete debridement of all infected tissue before reconstruction and carefully identify the coronary ostia before harvesting the coronary buttons. The PTFE conduit should be tailored to the appropriate length before right ventricular outflow tract (RVOT) reconstruction.
Outcome
The postoperative course was uncomplicated. The patient was extubated on postoperative day one, remained hemodynamically stable, and was discharged home after one week. Culture-directed antibiotic therapy was continued for six weeks. Follow-up clinical assessment and laboratory investigations demonstrated a satisfactory recovery with normalization of inflammatory markers.
References
- Loobuyck V, Soquet J, Moussa MD, et al. Active Aortic Endocarditis in Young Adults: Long-Term Results of the Ross Procedure. Ann Thorac Surg. 2020.
- Diaz-Castrillon CE, Viegas M, Castro-Medina M, et al. Pulmonary Homograft vs Handmade Polytetrafluoroethylene-Valved Conduits After the Ross Procedure. Ann Thorac Surg. 2023.
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