Free-Style Root Replacement and Annular Reconstruction for Destructive Aortic Root Endocarditis

Endocarditis involving the aortic root and annulus is still a surgical challenge. A porcine xenograft is a widely available substitute for homograft to perform this complex surgery. 

Patient Data 

This video presents the clinical case of a 53-year-old male who presented with severe aortic regurgitation.  

Transesophageal echocardiography showed infective endocarditis with perforation of the right aortic cusp and an abscess in the right coronary sinus. 

Procedure 

Upon opening the pericardium, severe hemorrhagic pericarditis was found, with the abscess extending to the right coronary ostia. 

After opening the aorta, perforation of the right aortic cusp was confirmed, with a deep abscess process just under the right portion of the aortic annulus. 

The aortic root was excised, creating buttons for the coronary arteries. The abscess on the right coronary sinus was debrided and irrigated with iodine solution. 

The portion of the aortic annulus involved in the endocarditic process was then reinforced with a heterologous pericardial patch, which was fixed to the ventricle-aortic junction with 4-0 polypropylene stitches. 

The aortic root was replaced with a porcine xenograft, anchored with 2-0 U pledgeted stitches. Knots were tied on a Hegar dilator to prevent narrowing of the aortic orifice. The left coronary ostia was reimplanted on the xenograft with a 5-0 polypropylene suture, while the right coronary button was reinforced with a heterologous pericardial strip.  

A straight vascular graft was employed to connect the xenograft to the ascending aorta. 

Postoperative echocardiography showed correct functioning of the aortic prosthesis with no pathological leaks and a mean gradient of 7 mmHg. 

References

1. Heinz A, Dumfarth J, Ruttmann-Ulmer E, Grimm M, Müller LC. Freestyle root replacement for complex destructive aortic valve endocarditis. J Thorac Cardiovasc Surg. 2014 Apr;147(4):1265-70

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