TAVR Explant for Endocarditis With Repair of Focal Invasion of the Left Fibrous Trigone

This case presentation demonstrates a transcatheter aortic valve replacement (TAVR) explant with repair of focal invasion of the left fibrous trigone in the left ventricular outflow tract (LVOT). 

The patient was a 76-year-old female who underwent TAVR with a bioprosthetic valve in 2023. She presented to the emergency room with fevers, tachycardia, and hypotension, at which point she was found to have Enterococcus faecalis bacteremia.  

Follow-up transesophageal echocardiogram (TEE) and computed tomography (CT) scan confirmed infective endocarditis of her TAVR prosthesis, with evidence of an abscess cavity. The TEE revealed an aortic root abscess near the left coronary cusp, showing flow through the abscess cavity into the left ventricle. The bioprosthetic valve leaflets appeared thickened but without an obvious mobile vegetation. The echocardiogram also demonstrated 1-2+ mitral regurgitation (MR) and 2-3+ tricuspid regurgitation (TR) due to annular dilation. 

By CT, an approximately 9x9 mm abscess cavity was appreciated along the aortic root near the left coronary cusp. Preoperative magnetic resonance imaging (MRI) demonstrated multifocal areas of faint diffusion restriction, raising concern for cardioembolic cerebrovascular accident (CVA). Follow-up magnetic resonance angiography (MRA) showed no large vessel occlusion or evidence of aneurysm, allowing the patient to be cleared for surgery. 

Following median sternotomy and standard aortic/bicaval cannulation, cardiac arrest was achieved with antegrade and direct retrograde cardioplegia. The interatrial septum was incised, and a basket sucker was placed across the mitral valve to vent the left heart. An aortotomy was made above the level of the bioprosthetic valve. The valve was gently teased away from the native valve leaflets, taking care to stay on the prosthesis and avoid damage to the aortic root. 

Once the prosthesis was removed, the native leaflets were excised, and the annulus was thoroughly debrided to healthy tissue. At this point, an annular defect along the left coronary cusp was observed, consistent with the root abscess seen on preoperative imaging. The invasion was focal at the left trigone area in the LVOT underneath the left cusp annulus: therefore, aortic root replacement was not indicated. Instead, it was decided to exclude the defect with a pericardial patch. 

The area was debrided of all unhealthy tissue. The cavity on the posterior aspect of the aortic root was unrooted for drainage to prevent walling off the abscess. This approach allowed for the avoidance of aortic root replacement in a high-risk patient while completely treating her infection. 

Once the debridement was complete, the aortic root was cleaned with chlorhexidine, irrigated, and sized for a #23 bioprosthesis. A triangular patch was created with bovine pericardium to repair the annular defect left by the abscess cavity, which had been externalized posteriorly. The patch was anchored to the LVOT with running sutures, and then secured into the aortic annulus and tied at the left noncoronary cusp commissure. 

After the LVOT patch repair, attention was turned to the mitral valve, which was repaired in the standard fashion using a #29 flexible annuloplasty band through a transseptal approach. The septum was then closed. Next, the aortic valve was replaced with noneverting pledgetted mattress sutures, taking bites through the patch along the left coronary cusp. The valve was seated and tied, and the aortotomy was closed. 

A tricuspid valve repair was then performed using a #30 band, and the right atrium was closed. The patient was subsequently weaned from cardiopulmonary bypass and decannulated. 

The patient came off of cardiopulmonary bypass with normal biventricular function, trivial MR and TR, and no paravalvular leak around the aortic prosthesis with low gradients. Postoperative CTA demonstrated intact repair with expected postoperative changes. 

Postoperatively, she was extubated on postoperative day zero and transferred out of the intensive care unit (ICU) on postoperative day two. She remained in the hospital for several days due to atrial flutter, which was medically treated, as well as physical rehabilitation and outpatient antibiotic setup. The patient was discharged in stable condition on postoperative day 15. 

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