Sealing the Source: Patch Repair of Aortic Root Abscess in Native Valve Endocarditis

Allograft root replacement remains the gold standard treatment for aortic root abscess but is often avoided due to its technical complexity. Patch repair of the aortic root is often done poorly, resulting in patient-prosthesis mismatch and early reoperation for valve dehiscence or reinfection. However, as demonstrated in the following cases, patch repair can be a suitable option.  

A 32-year-old patient with bicuspid aortic valve regurgitation and decreased ejection fraction presented with fevers, dyspnea, bacteremia, second degree atrioventricular (AV) block, and thickening of the noncoronary cusp and aortomitral curtain.  

He underwent a full sternotomy, central aortic and bicaval cannulation, and direct coronary sinus ostial retrograde cardioplegia.  

The aortic valve was excised, revealing an abscess that extended down the aortomitral curtain. This was thoroughly debrided, and the cavity was sterilized.  

Mechanical valve replacement was chosen rather than allograft due to the patient’s young age. An autologous pericardial patch was harvested and sewn along the anterior mitral annulus. The width of the patch was tailored to match the mitral annulus to avoid distorting the valve geometry.  

The patch was sewn up to the sinotubular junction bilaterally, effectively enlarging the aortic annulus and root while excluding the infected cavity. The patch was sewn with full-thickness bites of surrounding tissues. A 25 mm mechanical aortic valve was implanted. The patch was tailored to close the aorta in a tension-free fashion.  

Cardiopulmonary bypass was weaned with inotropic support. Transesophageal echocardiography (TEE) showed no paravalvular regurgitation and a low mean gradient. The patient did well, apart from the postoperative pacemaker implantation. 

Next, two months after extensive urological surgery, a 64-year-old patient presented with dyspnea, fevers, bacteremia, biventricular dysfunction, severe aortic and tricuspid regurgitation, thickening between the aorta and pulmonary artery, and cardiogenic shock with a low cardiac index.  

A full sternotomy was performed with central aortic and bicaval cannulation, and direct coronary sinus retrograde cardioplegia was delivered.

The aortic valve was excised, revealing an abscess that extended through the left-right commissure toward the pulmonary artery, along with a separate vegetation inside the pulmonary artery. The aorta and pulmonary arteries were transected to allow for complete debridement of infected tissue.  

The aortic root defect was reconstructed with an autologous pericardial patch.  

Since this area is not part of the fibrous skeleton of the heart, the patch was sewn with full-thickness bites of the aortic root and buttressed with strips of autologous pericardium externally. The patch was sewn up to the sinotubular junction. This reconstruction enlarged the aortic annulus and root, and a 25 mm tissue valve was implanted. The aorta was closed end-to-end, incorporating the patch.  

Cardiopulmonary bypass was weaned with inotropic and vasopressor support. TEE showed no paravalvular regurgitation and a low mean gradient. 

When repairing an aortic root abscess, completely debride and drain the infected areas and exclude them from the cardiovascular system. Allograft root replacement can accomplish this; however, when the abscess is located away from the coronary ostia, autologous pericardial patching can suffice. The patch must enlarge rather than shrink the aortic root and be anchored to durable tissue to avoid early reoperation for valve dehiscence, patient-prosthesis mismatch, or reinfection. 

References

1. Pettersson GB, Hussain ST, Shrestha NK, Gordon S, Fraser TG, Ibrahim KS, MD, Blackstone EH, MD. Infective endocarditis: An atlas of disease progression for describing, staging, coding, and understanding the pathology. J Thorac Cardiovasc Surg. 2014; 147:1142-1149
2. Smail H, Saxena P, Zimmet AD, McGiffin DC. Reconstruction and Replacement of the Aortic Root in Destructive Endocarditis. Operative Techniques in Thoracic and Cardiovascular Surgery 2016; 20(4): 336-354.
3. Charania JH, Atkinson L, Rokui S, Wong DR. Left-right commissural aortic root enlargement facilitates valve-in-valve transcatheter aortic valve implantation: A computed tomographic analysis. JTCVS Techniques 2025; 102139

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