Redo LVOT Reconstruction for Endocarditis

In this video, Dr. Vince Gaudiani demonstrates his technique for managing a complex case of endocarditis in a 59-year-old patient with a history of aortic and ascending aortic replacements.  

The video begins with a discussion about how to avoid pushing infected material to the patient’s brain or down the coronaries. 

Procedure 

After clamping and administering retrograde cardioplegia, the aorta was opened, revealing pus around the graft, necessitating the excision of the full ascending aortic graft while avoiding the pulmonary artery. The aortic valve prosthesis is then removed, which was heavily infected with debris.  The previous valve was 21 mm, but was positioned very near the coronary ostium and may have been too small.   

Once the aortic valve was removed, a significant amount of debris was also seen in the left ventricular outflow tract.  Extensive debridement was performed, including addressing a small hole in the membranous septum that needed repair.   

A Manouguian style aortic annulus enlargement was then performed by incising the annulus by the noncoronary cusp and excising an infected area of annulus.   

Next, horizontal pledgeted mattress sutures were placed, and a tire-style Dacron patch was made to close the small ventricular septal defect (VSD) but also act as an annulus suture for the valve.  A second patch was placed to enlarge the aortic annulus.   

A 23 mm bioprosthesis was then placed, followed by suturing an ascending aortic Dacron graft. The cross-clamp time was 93 minutes, and the patient is doing well four months later. 

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