Treatment of Infected Aortopulmonary Fistula With Double Pulmonary and Aortic Homograft

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The authors present the case of a 67-year-old patient who was referred to their institution with a one week history of fever and malaise. The patient had a past medical history of aortic valve replacement with a bioprosthetic valve five years prior to this episode. He was also diabetic and hypertensive. It was found that he had blood cultures positive for Streptococcus anginosus. A transthoracic echocardiography was performed, which demonstrated severe tricuspid regurgitation, and several vegetations on the aortic and pulmonary valves. The presence of bilateral infection, along with abnormal flow between the aorta and pulmonary artery, was suspicious for a fistula. A computed tomography (CT) scan confirmed the diagnosis and demonstrated a large filling defect in the pulmonary artery, likely due to a large vegetation on the pulmonary valve. The patient was consented for a redo sternotomy to treat his infection.  

After going on cardiopulmonary bypass, the heart was arrested, and the aortic bioprothesis was inspected. There were clear signs of active infection. Furthermore, a communication between the aorta and pulmonary artery could be identified near the right-left commissure. The pulmonary artery was transected, and the pulmonary valve was also inspected. A large vegetation was resected. The pulmonary root was dissected and completely resected. A 28 mm pulmonary homograft was used to replace the infected pulmonary root. Afterward, the excision of the infected bioprosthesis and debridement of the aortic root was completed. A 24 mm aortic homograft was then implanted using a series of interrupted 4-0 Prolene sutures. The coronary buttons were reimplanted in a standard fashion. Once the aortic homograft implantation was completed, the right atrium was opened, and the tricuspid valve was repaired using a 30 mm annuloplasty ring. A leadless pacemaker was also installed in the right ventricle. The atrium was closed, and the patient was weaned from cardiopulmonary bypass. On transesophageal echocardiography, there was new left ventricular dysfunction, which required reinstitution of cardiopulmonary bypass. The left coronary button was inspected and found to be patent with no kink. The left ventricular dysfunction was attributed to a possible embolization in the left anterior descending artery (LAD). A segment of saphenous vein was harvested, and the LAD was bypassed. The patient was then weaned easily from cardiopulmonary bypass. On echocardiography, the patient had good biventricular function. The aortic and pulmonary homografts both had trace regurgitation with mean gradients of 4 mmHg and 5 mmHg, respectively.  

The patient was extubated on postoperative day one. The remainder of his hospitalization was marked mainly by urinary retention, fluid overload, and BiPAP requirements. He was discharged home on postoperative day 13.   

References

1. El-Chami MF, Bonner M, Holbrook R et al. Leadless pacemakers reduce risk of device-related infection: Review of the potential mechanisms. Heart Rhythm 2020;17:1393-1397.

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