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Aortic root replacement for complicated bacterial endocarditis in an infant
Aortic Root Replacement for Complicated Bacterial Endocarditis in an Infant By Michael J. Perelman, Jeffrey Sugimoto, Rene A. Arcilla, and Robert B. Karp Chicago, Illinois 9 W e report the case of a 10-week-old girl with streptococcal aortic valve endocarditis that was resistant to medical management and complicated by aortic insufficiency, congestive heart failure, annular abscess, and a large periaortic pseudoaneurysm. She underwent successful aortic valve and root replacement (with coronary artery reimplantation) utilizing an aortic valve homograft (allograft). The patient recovered completely and was discharged 3 weeks postoperatively. To our knowledge, this is the youngest patient to receive an aortic homograft for bacterial endocarditis and annular abscess.
9 1989 by W,B. Saunders Company, INDEX W O R D S : Aortic homograft; bacterial endocarditis.
A C T E R I A L endocarditis in newborns and infants
B appears to be increasing in frequency. ~ Johnson et al found endocarditis in 0.8% of children under 2 years of age who had bacterial sepsis and in 10% of those who had concurrent congenital heart disease. 2 Poor results have previously limited surgical intervention for very young patients who have failed medical
Fig 1. Illustration of appearance of the aortic root at time of surgery. Arrow indicates the site of perforation and pseudoaneurysm formation.
management. 3 Aortic homografts facilitate aortic valve and root replacement in very young children and are not associated with most of the complications that plague xenografts and mechanical valves. CASE REPORT A 2.7-kg girl was the product of a full-term pregnancy; the baby was well until 6 weeks of age when she developed fever and irritability. Findings were consistent with group B streptococcal meningitis. Blood cultures drawn at that time were also positive for streptococcus. After 2 weeks of intravenous antibiotic therapy, her condition worsened and signs of congestive heart failure developed. Digoxin and diuretics were instituted, and an echocardiogram showed a l-cm vegetation on the posterior wall of the aortic root and moderate aortic insufficiency. After 4 weeks of therapy, she remained ill and was transferred to The University of Chicago for further evaluation. At that point she was afebrile, weighed 4.6 kg, and had moderate respiratory distress. There was an increased precordial impulse with a grade 3-4 over 6 to and fro systolicdiastolic murmur. Breath sounds were clear, but she had significant liver enlargement. Within 24 hours of admission, mechanical ventilation was required due to worsening respiratory distress, and cardiac tamponade developed necessitating subxyphoid pericardial window for drainage. Repeat echocardiogram demonstrated a vegetation in the aortic root, severe aortic insufficiency, and a probable aneurysm of the aortic root. Because of the patient's dismal prognosis and the presence of an aneurysmal aortic root, she underwent aortic valve and root replacement with reimplantation of the coronary arteries utilizing a 16-mm cryopreserved aortic homograft. At surgery, the left ventricle was dilated, but other chamber sizes were normal There was a large pulsatile mass that surrounded the aortic root and displaced the right atrium laterally and posteriorly and the pulmonary artery superiorly and to the left (Fig 1). The pulsatile mass proved to be a false aneurysm that communicated with the subvalvular left ventricular outflow tract through a perforation secondary to an abscess. To remove the pseudoaneurysm, drain the abscess, and replace the incompetent aortic valve, a valved tissue conduit was necessary. The proximal ascending aorta and aortic valve were resected down to ventricular muscle and the coronary arteries removed with a cuff of aorta. The cryopreserved homograft valve and ascending aortic segment were sutured directly to the base of the heart, following which the coronary arteries were reimplanted (Fig 2). Postoperatively, the patient did well and was discharged 3 weeks after operation. Follow-up echocardiogram performed prior to discharge showed a normally functioning valve without evidence of insufficiency or stenosis. Cardiac catheterization performed 4 months after surgery demonstrated trivial aortic insufficiency (Fig 3). She remains well 16 months after surgery, her growth pattern is
From the Departments of Surgery and Medicine, The University of Chicago, IL. Address reprint requests to Robert B. Karp, MD, Department of Surgery, Box 152. 5841 South Maryland, Chicago, IL 60637. 9 1989 by W.B. Saunders Company. 0022-3468/89/2411-0004503.00/0
Journal of Pediatric Surgery, Vol 24, No 11 (November),1989: pp 1121-1123
1121
1122
PERELMAN ET AL
at the 50th percentile, there has been no recurrent infection, and physical findings are significant only for a I/VI early diastolic
murmur. DISCUSSION
Fig 2. Illustration of the appearance of the aortic root after homograft valved conduit insertion and reimplantation of the coronary arteries.
Bacterial endocarditis is uncommon in newborns and infants but appears to be increasing in incidence. Presumably, management of the problems associated with prematurity using invasive monitoring, mechanical ventilation, and improved diagnostic techniques all contribute to this apparent rise in endocarditis. 4 The mainstay of treatment continues to consist of intravenous antibiotics and aggressive management of congestive heart failure. In the preantibiotic era, mortality was 100% and, even now, mortality remains at 20% to 25%. 5,6 Despite anecdotal reports of successful valve replacement in very young children, results with conventional devices have been disappointing. 7 In addition, these devices are not well suited for those infections that cause extensive damage to the aortic root. Thus, pediatricians and surgeons have in the past been reluctant to pursue vane replacement for very young patients with severe aortic valve disease. The trivial aortic insufficiency present postoperatively in this case is not unusual; it is not inconsistent with normal graft function and does not signal valve deterioration. Furthermore, it is likely that the homograft will permit normal growth to adulthood. Despite earlier failures related to tissue degeneration, aortic
Fig 3. Cineangiogram demonstrating the aortic root and ascending aorta four months after surgery, (A) Left ventriculogram showing large aortic conduit compared to left ventricular chamber size. (B) Aortic root injection showing trivial aortic insufficiency.
AORTIC ROOT REPLACEMENT
1123
h o m o g r a f t s u s i n g new c r y o p r e s e r v a t i o n t e c h n i q u e s w o u l d s e e m to o b v i a t e p r e v i o u s p r o b l e m s . E v i d e n c e i n d i c a t e s t h a t tissue f a i l u r e is likely to be u n c o m m o n , a l a r g e v a r i e t y o f valve sizes a r e available for i m p l a n t a tion, and a n t i c o a g u l a t i o n is u n n e c e s s a r y . 8'9 T h u s , w i t h
the e x c e p t i o n o f e l d e r l y p a t i e n t s , we feel t h a t h o m o g r a f t s a r e t h e v a l v e of c h o i c e in t h e a o r t i c position. A s this c a s e illustrates, t h e h o m o g r a f t a o r t i c v a l v e c o n d u i t also offers an e f f e c t i v e option for aortic valve a n d root r e p l a c e m e n t . 1~
REFERENCES
1. Edwards K, Ingall D, Czapek E, et al: Bacterial endocarditis in 4 young infants. Clin Pediatr 16:607-609, 1977 2. Johnson DH, Rosenthal A, Nadas AS: Bacterial endocarditis in children under 2 years of age. Am J Dis 29:183-186, 1975 3. Wittig J, McConnell D, Buckberg G, et al: Aortic valve replacement in the young child. Ann Thorac Surg 19:40-46, 1975 4. McGuinness GA, Schieken RM, Maguire GF: Endocarditis in the newborn. Am J Dis Child 134:577-580, 1980 5. Gersony WM, Hordof A J: Infective endocarditis and disease of the pericardium. Pediatr Clin North Am 25:83 t-846, 1978 6. Stanton BF, Baltimore RS, Clemens JD: Changing spectrum of infective endocarditis in children. Am J Dis Child 138:720-725, 1984
7. Kersten TE, Bessinger FB, Stone FM, et al: Combined techniques for double valve replacement in the infant. Ann Thorac Surg 39:180-184, 1985 8. Somervillle J, Ross DM: Homograft replacement of aortic root with reimplantation of coronary arteries Results after one to five years. Br Heart J 47:473-492, 1982 9. O'Brien MF, Stafford G, Gardner M, et al: The viable cryopreserved allograft aortic valve. J Cardiac Surg 2:153-167, 1987 (suppl) 10. Donaldson RM, Ross DM: Homograft aortic root relacement for complicated prosthetic valve endocarditis. Circulation 70:178181, 1984 (suppl 1)
9 1989 by W,B. Saunders Company, INDEX W O R D S : Aortic homograft; bacterial endocarditis.
A C T E R I A L endocarditis in newborns and infants
B appears to be increasing in frequency. ~ Johnson et al found endocarditis in 0.8% of children under 2 years of age who had bacterial sepsis and in 10% of those who had concurrent congenital heart disease. 2 Poor results have previously limited surgical intervention for very young patients who have failed medical
Fig 1. Illustration of appearance of the aortic root at time of surgery. Arrow indicates the site of perforation and pseudoaneurysm formation.
management. 3 Aortic homografts facilitate aortic valve and root replacement in very young children and are not associated with most of the complications that plague xenografts and mechanical valves. CASE REPORT A 2.7-kg girl was the product of a full-term pregnancy; the baby was well until 6 weeks of age when she developed fever and irritability. Findings were consistent with group B streptococcal meningitis. Blood cultures drawn at that time were also positive for streptococcus. After 2 weeks of intravenous antibiotic therapy, her condition worsened and signs of congestive heart failure developed. Digoxin and diuretics were instituted, and an echocardiogram showed a l-cm vegetation on the posterior wall of the aortic root and moderate aortic insufficiency. After 4 weeks of therapy, she remained ill and was transferred to The University of Chicago for further evaluation. At that point she was afebrile, weighed 4.6 kg, and had moderate respiratory distress. There was an increased precordial impulse with a grade 3-4 over 6 to and fro systolicdiastolic murmur. Breath sounds were clear, but she had significant liver enlargement. Within 24 hours of admission, mechanical ventilation was required due to worsening respiratory distress, and cardiac tamponade developed necessitating subxyphoid pericardial window for drainage. Repeat echocardiogram demonstrated a vegetation in the aortic root, severe aortic insufficiency, and a probable aneurysm of the aortic root. Because of the patient's dismal prognosis and the presence of an aneurysmal aortic root, she underwent aortic valve and root replacement with reimplantation of the coronary arteries utilizing a 16-mm cryopreserved aortic homograft. At surgery, the left ventricle was dilated, but other chamber sizes were normal There was a large pulsatile mass that surrounded the aortic root and displaced the right atrium laterally and posteriorly and the pulmonary artery superiorly and to the left (Fig 1). The pulsatile mass proved to be a false aneurysm that communicated with the subvalvular left ventricular outflow tract through a perforation secondary to an abscess. To remove the pseudoaneurysm, drain the abscess, and replace the incompetent aortic valve, a valved tissue conduit was necessary. The proximal ascending aorta and aortic valve were resected down to ventricular muscle and the coronary arteries removed with a cuff of aorta. The cryopreserved homograft valve and ascending aortic segment were sutured directly to the base of the heart, following which the coronary arteries were reimplanted (Fig 2). Postoperatively, the patient did well and was discharged 3 weeks after operation. Follow-up echocardiogram performed prior to discharge showed a normally functioning valve without evidence of insufficiency or stenosis. Cardiac catheterization performed 4 months after surgery demonstrated trivial aortic insufficiency (Fig 3). She remains well 16 months after surgery, her growth pattern is
From the Departments of Surgery and Medicine, The University of Chicago, IL. Address reprint requests to Robert B. Karp, MD, Department of Surgery, Box 152. 5841 South Maryland, Chicago, IL 60637. 9 1989 by W.B. Saunders Company. 0022-3468/89/2411-0004503.00/0
Journal of Pediatric Surgery, Vol 24, No 11 (November),1989: pp 1121-1123
1121
1122
PERELMAN ET AL
at the 50th percentile, there has been no recurrent infection, and physical findings are significant only for a I/VI early diastolic
murmur. DISCUSSION
Fig 2. Illustration of the appearance of the aortic root after homograft valved conduit insertion and reimplantation of the coronary arteries.
Bacterial endocarditis is uncommon in newborns and infants but appears to be increasing in incidence. Presumably, management of the problems associated with prematurity using invasive monitoring, mechanical ventilation, and improved diagnostic techniques all contribute to this apparent rise in endocarditis. 4 The mainstay of treatment continues to consist of intravenous antibiotics and aggressive management of congestive heart failure. In the preantibiotic era, mortality was 100% and, even now, mortality remains at 20% to 25%. 5,6 Despite anecdotal reports of successful valve replacement in very young children, results with conventional devices have been disappointing. 7 In addition, these devices are not well suited for those infections that cause extensive damage to the aortic root. Thus, pediatricians and surgeons have in the past been reluctant to pursue vane replacement for very young patients with severe aortic valve disease. The trivial aortic insufficiency present postoperatively in this case is not unusual; it is not inconsistent with normal graft function and does not signal valve deterioration. Furthermore, it is likely that the homograft will permit normal growth to adulthood. Despite earlier failures related to tissue degeneration, aortic
Fig 3. Cineangiogram demonstrating the aortic root and ascending aorta four months after surgery, (A) Left ventriculogram showing large aortic conduit compared to left ventricular chamber size. (B) Aortic root injection showing trivial aortic insufficiency.
AORTIC ROOT REPLACEMENT
1123
h o m o g r a f t s u s i n g new c r y o p r e s e r v a t i o n t e c h n i q u e s w o u l d s e e m to o b v i a t e p r e v i o u s p r o b l e m s . E v i d e n c e i n d i c a t e s t h a t tissue f a i l u r e is likely to be u n c o m m o n , a l a r g e v a r i e t y o f valve sizes a r e available for i m p l a n t a tion, and a n t i c o a g u l a t i o n is u n n e c e s s a r y . 8'9 T h u s , w i t h
the e x c e p t i o n o f e l d e r l y p a t i e n t s , we feel t h a t h o m o g r a f t s a r e t h e v a l v e of c h o i c e in t h e a o r t i c position. A s this c a s e illustrates, t h e h o m o g r a f t a o r t i c v a l v e c o n d u i t also offers an e f f e c t i v e option for aortic valve a n d root r e p l a c e m e n t . 1~
REFERENCES
1. Edwards K, Ingall D, Czapek E, et al: Bacterial endocarditis in 4 young infants. Clin Pediatr 16:607-609, 1977 2. Johnson DH, Rosenthal A, Nadas AS: Bacterial endocarditis in children under 2 years of age. Am J Dis 29:183-186, 1975 3. Wittig J, McConnell D, Buckberg G, et al: Aortic valve replacement in the young child. Ann Thorac Surg 19:40-46, 1975 4. McGuinness GA, Schieken RM, Maguire GF: Endocarditis in the newborn. Am J Dis Child 134:577-580, 1980 5. Gersony WM, Hordof A J: Infective endocarditis and disease of the pericardium. Pediatr Clin North Am 25:83 t-846, 1978 6. Stanton BF, Baltimore RS, Clemens JD: Changing spectrum of infective endocarditis in children. Am J Dis Child 138:720-725, 1984
7. Kersten TE, Bessinger FB, Stone FM, et al: Combined techniques for double valve replacement in the infant. Ann Thorac Surg 39:180-184, 1985 8. Somervillle J, Ross DM: Homograft replacement of aortic root with reimplantation of coronary arteries Results after one to five years. Br Heart J 47:473-492, 1982 9. O'Brien MF, Stafford G, Gardner M, et al: The viable cryopreserved allograft aortic valve. J Cardiac Surg 2:153-167, 1987 (suppl) 10. Donaldson RM, Ross DM: Homograft aortic root relacement for complicated prosthetic valve endocarditis. Circulation 70:178181, 1984 (suppl 1)