Homograft Surgery for Infective Endocarditis

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Preoperative Transesophageal Echocardiogram (TEE) 

Pre-procedure intraoperative TEE revealed left ventricular ejection fraction (LVEF) of 50 percent, severe aortic regurgitation, large vegetations on the aortic valve and the tricuspid valve, and a communicating abscess between the right atrium (RA) and the aortic root. 

Procedure 

After the lines were placed, a median sternotomy was performed. Central aortic cannulation and bicaval cannulation were performed using a long femoral inferior vena cava (IVC) cannula and a short superior vena cava (SVC) cannula. After initiating the cardiopulmonary bypass (CPB), a right atriotomy was performed, and the retrograde cannula was secured in the coronary sinus. The aortic cross-clamp was placed, and retrograde cardioplegia was administered before the aorta was opened, followed by direct ostial antegrade cardioplegia administration. 

Once the aorta was opened, large vegetations were noted on the right and left aortic valve leaflets, and a large abscess cavity communicating with the right atrium was identified. Infected tissue was debrided, and the root along with the coronary buttons were mobilized. The fistula was further debrided and closed with a bovine pericardial patch through the right atrium. 

The aortic annulus and left ventricular outflow tract (LVOT) measured at 25 mm and a decision was made to use a 24 mm human cadaver homograft instead of the Valsalva graft due to extensive infection and tissue destruction. The homograft was selected because it is more flexible and fits better in this case. The homograft was secured in place via the intra-annular technique by placing horizontal mattress sutures with 3-0 Prolene sutures and a bovine pericardial strip placed outside the annulus. This approach allows for more even distribution of suture tension compared to the running technique. 

Next, the left and right coronary buttons were reimplanted using 5-0 Prolene sutures. The hemostasis was confirmed by filling the homograft with antegrade cardioplegia. Finally, the distal ascending aorta and graft anastomosis were completed with 4-0 Prolene sutures. Infected tissue was then debrided from the tricuspid valve. Given the severe destruction of the tricuspid valve, a decision was made to replace it with a 33 mm mitral tissue valve, which was inserted intra-annularly using 2-0 pledgeted sutures. The right atrium was subsequently closed. The aortic cross-clamp was removed, and the patient was weaned off CPB. The total CPB time was 282 minutes, and the aortic cross-clamp time was 207 minutes. 

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