- Email: [email protected]
Stentless Xenograft Repair of the Dissected Aortic Root
1448
CASE REPORT WESTABY ET AL DISSECTED ROOT REPAIR
Comment The incidence of redundancy of the transposed colon is probably underestimated because many patients adjust their lifestyle after esophageal replacement and do not report occasional regurgitation or aspiration symptoms. Only a few series have investigated the late radiologic results of colon interposition. A long-term follow-up study by Kelly and associates [1] demonstrated a redundancy of the interposed colon in 4 of 18 children (22%) at a mean of 10.4 years after the operation. However, only 1 patient was symptomatic and complained of heartburn and regurgitation. Isolauri and colleagues [2] reported redundancy of the colon graft in 4 of 50 adult patients (8%) undergoing radiographic examination at an average of 71 months after the operation. A more recent study by Mutaf and coworkers [3] showed a redundant interposed colon in 19 of 90 children (21.1%); redundancy was less common when the retrosternal route was employed. Nocturnal emesis and occasional melena were the most frequent complaints; half of these patients preferred to sleep in the prone position to facilitate emptying of the colon graft. The redundancy of the interposed colon may be caused by stricture of the cologastric anastomosis, impaired gastric emptying, or a transposed graft that is too long. Mechanical obstruction at the retrosternal hiatus also may be responsible for proximal dilatation and redundancy of a retrosternal colon graft. Over the years, stasis of food debris may in turn aggravate the dilatation of the colon and lead to disabling symptoms. However, in most patients this abnormality is asymptomatic and other reasons for symptoms should be ruled out such as delayed gastric emptying secondary to vagotomy [4]. The redundant transposed colon can be surgically corrected by taking down the cologastric anastomosis and either implanting the colon downward in the stomach or resecting the colonic loop [5]. Extreme care must be taken to preserve the marginal vessels during the dissection. The technique we describe herein obviates the need for a redo cologastric anastomosis and may reduce the risk of injury to the marginal vessels. In addition, the stapled colocolonic anastomosis is quick, safe, and easy to perform. The same procedure might be performed transthoracically when the redundant colon graft lies in the posterior mediastinal route.
References 1. Kelly J, Shackelford G, Roper C. Esophageal replacement with colon in children: functional results and long-term growth. Ann Thorac Surg 1983;36:634– 43. 2. Isolauri J, Paakkala T, Arajarvi P, Markkula H. Colon interposition. Long-term radiographic results. Eur J Radiol 1987;7: 248–52. 3. Mutaf O, Ozok G, Avanoglu A. Oesophagoplasty in the treatment of caustic oesophageal strictures in children. Br J Surg 1995;82:644– 6. © 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;65:1448 –50
4. DeMeester T, Kauer W. The colon as an esophageal substitute. Dis Esoph 1995;8:20–9. 5. Schein M, Conlan A, Hatchuel D. Surgical management of the redundant transposed colon. Am J Surg 1990;160:529–30.
Stentless Xenograft Repair of the Dissected Aortic Root Stephen Westaby, FRCS, Takahiro Katsumata, MD, Remi Houel, MD, and Amihay Shinfeld, MD Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Oxford, England
We used a Freestyle (Medtronic, Minneapolis, MN) porcine root to replace a regurgitant aortic valve and repair acute type A dissection. A Hemashield (Meadox Medicals, Oakland, NJ) graft was used to replace the ascending aorta with the “open anastomosis” technique. This method is a valuable alternative to conventional root replacement in acute type A dissection. (Ann Thorac Surg 1998;65:1448 –50) © 1998 by The Society of Thoracic Surgeons
A
ortic valve preservation is preferable in acute type A dissection [1, 2]. This is achieved with gelatinresorcin-formol glue or conventional valve resuspension for the majority of patients, but for those with extensive disruption of the root or organic aortic valve disease, aortic root replacement is necessary [3, 4]. Even in experienced hands, aortic root replacement for type A dissection is associated with substantial mortality [5]. In an alternative approach we employed valve replacement and endoaortic root repair using a stentless porcine xenograft. The 77-year-old man had been followed up with poorly controlled hypertension, aortic regurgitation, and atrial fibrillation. He suffered sudden severe chest pain radiating to the back while sitting in his doctor’s waiting room. After a delay of 18 hours, transesophageal echocardiography confirmed the diagnosis of acute type A dissection, and he was referred for an operation. His systemic blood pressure was 220/50 mm Hg, the serum creatinine level was raised, and he was fully anticoagulated with an international normalized ratio of 3.0. At operation, the right femoral artery was exposed and cannulated for arterial return. Median stenotomy was performed, and blood was evacuated from the pericardium. Cardiopulmonary bypass was established with a two-stage venous cannula in the right atrium. Systemic
Accepted for publication Dec 2, 1997. Address reprint requests to Mr Westaby, Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, England.
0003-4975/98/$19.00 PII S0003-4975(98)00163-5
Ann Thorac Surg 1998;65:1448 –50
CASE REPORT WESTABY ET AL DISSECTED ROOT REPAIR
1449
longer encounters dissected tissue within the neoroot (Fig 1). A 28 mm Hemashield (Meadox Medicals, Oakland, NJ) graft was then sewn to the outflow of the xenograft, which further reinforced the repair. Hypothermic circulatory arrest was then employed with a head-down tilt. The aortic cross-clamp was removed and the site of cross-clamping was excised. The distal anastomosis between the Hemashield graft and the proximal arch was performed after reconstitution of the dissected arch with gelatin-resorcin-formol glue [7] (Fig 2). The root and arch were deaired and cardiopulmonary bypass was resumed with full rewarming. Cardiopulmonary bypass was then discontinued without difficulty. The patient was alert and extubated after 8 hours in the recovery room. The patient was in New York Heart Association class I at 8 months after the operation. Echocardiography showed a fully competent aortic valve and no residual aneurysm.
Comment Fig 1. Porcine aortic root implanted in a “cylinder-within-cylinder” fashion. The dissected layers were sewn to the outflow aspect of the porcine root.
cooling to 20°C was commenced pending total circulatory arrest for the open distal anastomosis. When cooling of the head was confirmed, an aortic cross-clamp was applied 2 cm proximal to the innominate artery to obtain cardioplegic arrest and allow performance of aortic root repair during the cooling period. With the aorta open, the internal diameters of the sinotubular junction and the aortic annulus were 3.5 and 3.0 cm, respectively. The aortic valve was congenitally bicuspid with both stenosis and regurgitation. Dissection involved the coronary ostia. Conventional glue resuspension of the valve was inappropriate, but to avoid aortic root replacement in a high-risk patient we elected to implant a porcine aortic root within the native sinuses without formal mobilization and reimplantation of coronary buttons. The native aorta was transected 1 cm above the sinotubular junction. The diseased aortic cusps were excised and the inflow sutures of 2.0 Ticron (Davis & Geck, Danbury, CT) were inserted into the annulus as described previously [6]. The Freestyle (Medtronic, Minneapolis, MN) valve was then sewn into the annulus as a full porcine aortic root with the coronary arteries ligated. The porcine coronary buttons were then removed and the aortic root repaired with a single running suture of 4-0 Prolene (Ethicon, Somerville, NJ). This suture line reconstituted the aortic wall by sewing the dissected layers to the outflow aspect of the porcine root. The native coronary arteries were left in situ but included in the repair by diversion of the outflow suture line below the coronary ostia in a manner similar to that described for Freestyle valve implantation by the modified subcoronary method [6]. With this technique, ejected blood no
For this anticoagulated patient with acute type A dissection, the porcine root inclusion method provided a simple and effective alternative to full aortic root replacement by the Bentall method. The dissected native root was excluded but enclosed the porcine root, which prevented bleeding. In turn, the stentless xenograft provided excellent hemodynamics without the need for anticoagulation (in sinus rhythm) [8]. Although theoretically it would have been possible to use an aortic homograft, the stentless xenograft is easier to size and more user friendly for this indication. Although we advocate gelatin-resorcin-formol glue repair of the aortic sinuses in all patients without Marfan’s
Fig 2. Dissection repair completed by ascending aortic replacement with a Dacron graft.
1450
CASE REPORT PRAT ET AL PULMONARY AUTOGRAFT AND MITRAL HOMOGRAFT
syndrome who have a normal valve before dissection, this approach is not feasible for patients with a stenotic bicuspid valve or annuloaortic ectasia. Most of these patients require valve replacement. Although our policy of root repair for virtually all patients without Marfan’s syndrome has provided an overall operative mortality of 6% [1], others suggest that preservation of the native aortic valve is possible in only 70% to 80% of operations and advise radical root replacement for the remainder [4, 5]. A recent report from Ergin and colleagues [5] considered an operative mortality of 15.7% for root replacement as favorable compared with mortality rates of 15% for valve resuspension or 25% for separate valve and ascending aortic replacement in the combined Stanford-Duke series [4]. Although the Bentall procedure and radical root repair (with mobilization and reimplantation of dissected coronary arteries) can be achieved with acceptable operative mortality by those with experience, the majority of patients are operated on under emergency conditions by surgeons with limited exposure to aortic root surgery. We emphasize that operative survival is of paramount importance and an expeditious and simple operation is most likely to achieve this. Complete transection of the aorta above the sinotubular junction and exclusion of the dissected sinuses with a xenograft aortic root provided an effective alternative for this elderly patient in whom valve repair was inappropriate. Because the Dacron inflow cloth of the Freestyle valve prevents annular dilatation, the method may also be suitable for some patients with Marfan’s syndrome and others who would prefer to avoid anticoagulation. In conclusion, we consider the xenograft root inclusion method a simpler approach to radical root replacement when the native valve cannot be repaired.
References 1. Westaby S, Katsumata T, Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg 1997;64:1108–12. 2. Von Segesser LK, Renzelti E, Lachat M, et al. Aortic valve preservation in acute type A dissection. Is it sound? J Thorac Cardiovasc Surg 1996;111:381–91. 3. Fann JI, Glower DD, Miller DC, et al. Preservation of aortic valve in acute type A dissection complicated by aortic valve regurgitation. J Thorac Cardiovasc Surg 1991;102:62–75. 4. Miller DC, Mitchell RS, Oyer PE, et al. Independent determination of operative mortality for patients with aortic dissections. Circulation 1984;70(Suppl 1):153– 64. 5. Ergin MA, McCullough J, Galla JD, et al. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996;10:840–5. 6. Westaby S, Narasena N, Ormerod O, et al. Time related hemodynamic changes after aortic valve replacement with the Freestyle stentless valve. Ann Thorac Surg 1995;60:1633–9. 7. Bachet J, Goudot B, Teodori G, et al. Surgery of type A acute aortic dissection with gelatine-resorcine-formol biological glue. A twelve year experience. J Cardiovasc Surg 1990;31: 263–73. 8. Jin XY, Westaby S, Gibson R, et al. Left ventricular remodelling and improvement of Freestyle stentless valve haemodynamics. Eur J Cardiothorac Surg 1997;12:63–9. © 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;65:1450 –2
Ross Operation and Mitral Homograft for Aortic and Tricuspid Valve Endocarditis Alain Prat, MD, Olivier H. Fabre, MD, Andre´ Vincentelli, MD, Vincent Doisy, MD, and Ghatfan Shaaban, MD Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Re´gional et Universitaire de Lille, Lille, France
We report here a case of concomitant aortic and tricuspid valve endocarditis occurring in a 26-year-old woman 2 weeks after she had given birth by cesarean delivery. Preoperative transthoracic echocardiography revealed a previously undetected aorta–right atrium fistula, which at operation appeared to be congenital in origin. Surgical treatment consisted of aortic valve replacement with a pulmonary autograft, tricuspid valve replacement with a cryopreserved mitral homograft, and closure of the fistulous communication. The postoperative recovery was uneventful. (Ann Thorac Surg 1998;65:1450 –2) © 1998 by The Society of Thoracic Surgeons
S
everal surgical techniques have been reported for the treatment of infective endocarditis. These include the use of mechanical valves, bioprotheses, homografts, or pulmonary autografts. Although the choice of surgical technique remains debatable, it has been established that the radical excision of all infected tissue is a prerequisite for the successful treatment of the condition. We report here a case of aortic and tricuspid valve endocarditis associated with a congenital aorta–right atrium fistula treated with a Ross procedure and a cryopreserved mitral homograft. A 26-year-old woman was referred to the emergency department in April 1997 for acute dyspnea, weakness, and persistent fever. Her medical history revealed only an unexplored grade 2/6 systolodiastolic murmur and a cesarean delivery 15 days earlier. A physical examination of the patient disclosed a grade 4/6 systolic and diastolic murmur. A chest radiograph showed mild cardiomegaly, and the electrocardiogram showed a sinusal tachycardia. Transthoracic Doppler echocardiography revealed a massive aortic and tricuspid regurgitation, and several vegetations were observed on the posterior leaflet of the tricuspid valve. A fistula was noted with a continuous flow (. 4 m/s) between the noncoronary sinus and the right atrium. These data confirmed the diagnosis of acute
Accepted for publication Dec 3, 1997. Address reprint requests to Dr Prat, Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Regional Universitaire, 59037 Lille Cedex, France (e-mail: [email protected]).
0003-4975/98/$19.00 PII S0003-4975(98)00100-3
CASE REPORT WESTABY ET AL DISSECTED ROOT REPAIR
Comment The incidence of redundancy of the transposed colon is probably underestimated because many patients adjust their lifestyle after esophageal replacement and do not report occasional regurgitation or aspiration symptoms. Only a few series have investigated the late radiologic results of colon interposition. A long-term follow-up study by Kelly and associates [1] demonstrated a redundancy of the interposed colon in 4 of 18 children (22%) at a mean of 10.4 years after the operation. However, only 1 patient was symptomatic and complained of heartburn and regurgitation. Isolauri and colleagues [2] reported redundancy of the colon graft in 4 of 50 adult patients (8%) undergoing radiographic examination at an average of 71 months after the operation. A more recent study by Mutaf and coworkers [3] showed a redundant interposed colon in 19 of 90 children (21.1%); redundancy was less common when the retrosternal route was employed. Nocturnal emesis and occasional melena were the most frequent complaints; half of these patients preferred to sleep in the prone position to facilitate emptying of the colon graft. The redundancy of the interposed colon may be caused by stricture of the cologastric anastomosis, impaired gastric emptying, or a transposed graft that is too long. Mechanical obstruction at the retrosternal hiatus also may be responsible for proximal dilatation and redundancy of a retrosternal colon graft. Over the years, stasis of food debris may in turn aggravate the dilatation of the colon and lead to disabling symptoms. However, in most patients this abnormality is asymptomatic and other reasons for symptoms should be ruled out such as delayed gastric emptying secondary to vagotomy [4]. The redundant transposed colon can be surgically corrected by taking down the cologastric anastomosis and either implanting the colon downward in the stomach or resecting the colonic loop [5]. Extreme care must be taken to preserve the marginal vessels during the dissection. The technique we describe herein obviates the need for a redo cologastric anastomosis and may reduce the risk of injury to the marginal vessels. In addition, the stapled colocolonic anastomosis is quick, safe, and easy to perform. The same procedure might be performed transthoracically when the redundant colon graft lies in the posterior mediastinal route.
References 1. Kelly J, Shackelford G, Roper C. Esophageal replacement with colon in children: functional results and long-term growth. Ann Thorac Surg 1983;36:634– 43. 2. Isolauri J, Paakkala T, Arajarvi P, Markkula H. Colon interposition. Long-term radiographic results. Eur J Radiol 1987;7: 248–52. 3. Mutaf O, Ozok G, Avanoglu A. Oesophagoplasty in the treatment of caustic oesophageal strictures in children. Br J Surg 1995;82:644– 6. © 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;65:1448 –50
4. DeMeester T, Kauer W. The colon as an esophageal substitute. Dis Esoph 1995;8:20–9. 5. Schein M, Conlan A, Hatchuel D. Surgical management of the redundant transposed colon. Am J Surg 1990;160:529–30.
Stentless Xenograft Repair of the Dissected Aortic Root Stephen Westaby, FRCS, Takahiro Katsumata, MD, Remi Houel, MD, and Amihay Shinfeld, MD Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Oxford, England
We used a Freestyle (Medtronic, Minneapolis, MN) porcine root to replace a regurgitant aortic valve and repair acute type A dissection. A Hemashield (Meadox Medicals, Oakland, NJ) graft was used to replace the ascending aorta with the “open anastomosis” technique. This method is a valuable alternative to conventional root replacement in acute type A dissection. (Ann Thorac Surg 1998;65:1448 –50) © 1998 by The Society of Thoracic Surgeons
A
ortic valve preservation is preferable in acute type A dissection [1, 2]. This is achieved with gelatinresorcin-formol glue or conventional valve resuspension for the majority of patients, but for those with extensive disruption of the root or organic aortic valve disease, aortic root replacement is necessary [3, 4]. Even in experienced hands, aortic root replacement for type A dissection is associated with substantial mortality [5]. In an alternative approach we employed valve replacement and endoaortic root repair using a stentless porcine xenograft. The 77-year-old man had been followed up with poorly controlled hypertension, aortic regurgitation, and atrial fibrillation. He suffered sudden severe chest pain radiating to the back while sitting in his doctor’s waiting room. After a delay of 18 hours, transesophageal echocardiography confirmed the diagnosis of acute type A dissection, and he was referred for an operation. His systemic blood pressure was 220/50 mm Hg, the serum creatinine level was raised, and he was fully anticoagulated with an international normalized ratio of 3.0. At operation, the right femoral artery was exposed and cannulated for arterial return. Median stenotomy was performed, and blood was evacuated from the pericardium. Cardiopulmonary bypass was established with a two-stage venous cannula in the right atrium. Systemic
Accepted for publication Dec 2, 1997. Address reprint requests to Mr Westaby, Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, England.
0003-4975/98/$19.00 PII S0003-4975(98)00163-5
Ann Thorac Surg 1998;65:1448 –50
CASE REPORT WESTABY ET AL DISSECTED ROOT REPAIR
1449
longer encounters dissected tissue within the neoroot (Fig 1). A 28 mm Hemashield (Meadox Medicals, Oakland, NJ) graft was then sewn to the outflow of the xenograft, which further reinforced the repair. Hypothermic circulatory arrest was then employed with a head-down tilt. The aortic cross-clamp was removed and the site of cross-clamping was excised. The distal anastomosis between the Hemashield graft and the proximal arch was performed after reconstitution of the dissected arch with gelatin-resorcin-formol glue [7] (Fig 2). The root and arch were deaired and cardiopulmonary bypass was resumed with full rewarming. Cardiopulmonary bypass was then discontinued without difficulty. The patient was alert and extubated after 8 hours in the recovery room. The patient was in New York Heart Association class I at 8 months after the operation. Echocardiography showed a fully competent aortic valve and no residual aneurysm.
Comment Fig 1. Porcine aortic root implanted in a “cylinder-within-cylinder” fashion. The dissected layers were sewn to the outflow aspect of the porcine root.
cooling to 20°C was commenced pending total circulatory arrest for the open distal anastomosis. When cooling of the head was confirmed, an aortic cross-clamp was applied 2 cm proximal to the innominate artery to obtain cardioplegic arrest and allow performance of aortic root repair during the cooling period. With the aorta open, the internal diameters of the sinotubular junction and the aortic annulus were 3.5 and 3.0 cm, respectively. The aortic valve was congenitally bicuspid with both stenosis and regurgitation. Dissection involved the coronary ostia. Conventional glue resuspension of the valve was inappropriate, but to avoid aortic root replacement in a high-risk patient we elected to implant a porcine aortic root within the native sinuses without formal mobilization and reimplantation of coronary buttons. The native aorta was transected 1 cm above the sinotubular junction. The diseased aortic cusps were excised and the inflow sutures of 2.0 Ticron (Davis & Geck, Danbury, CT) were inserted into the annulus as described previously [6]. The Freestyle (Medtronic, Minneapolis, MN) valve was then sewn into the annulus as a full porcine aortic root with the coronary arteries ligated. The porcine coronary buttons were then removed and the aortic root repaired with a single running suture of 4-0 Prolene (Ethicon, Somerville, NJ). This suture line reconstituted the aortic wall by sewing the dissected layers to the outflow aspect of the porcine root. The native coronary arteries were left in situ but included in the repair by diversion of the outflow suture line below the coronary ostia in a manner similar to that described for Freestyle valve implantation by the modified subcoronary method [6]. With this technique, ejected blood no
For this anticoagulated patient with acute type A dissection, the porcine root inclusion method provided a simple and effective alternative to full aortic root replacement by the Bentall method. The dissected native root was excluded but enclosed the porcine root, which prevented bleeding. In turn, the stentless xenograft provided excellent hemodynamics without the need for anticoagulation (in sinus rhythm) [8]. Although theoretically it would have been possible to use an aortic homograft, the stentless xenograft is easier to size and more user friendly for this indication. Although we advocate gelatin-resorcin-formol glue repair of the aortic sinuses in all patients without Marfan’s
Fig 2. Dissection repair completed by ascending aortic replacement with a Dacron graft.
1450
CASE REPORT PRAT ET AL PULMONARY AUTOGRAFT AND MITRAL HOMOGRAFT
syndrome who have a normal valve before dissection, this approach is not feasible for patients with a stenotic bicuspid valve or annuloaortic ectasia. Most of these patients require valve replacement. Although our policy of root repair for virtually all patients without Marfan’s syndrome has provided an overall operative mortality of 6% [1], others suggest that preservation of the native aortic valve is possible in only 70% to 80% of operations and advise radical root replacement for the remainder [4, 5]. A recent report from Ergin and colleagues [5] considered an operative mortality of 15.7% for root replacement as favorable compared with mortality rates of 15% for valve resuspension or 25% for separate valve and ascending aortic replacement in the combined Stanford-Duke series [4]. Although the Bentall procedure and radical root repair (with mobilization and reimplantation of dissected coronary arteries) can be achieved with acceptable operative mortality by those with experience, the majority of patients are operated on under emergency conditions by surgeons with limited exposure to aortic root surgery. We emphasize that operative survival is of paramount importance and an expeditious and simple operation is most likely to achieve this. Complete transection of the aorta above the sinotubular junction and exclusion of the dissected sinuses with a xenograft aortic root provided an effective alternative for this elderly patient in whom valve repair was inappropriate. Because the Dacron inflow cloth of the Freestyle valve prevents annular dilatation, the method may also be suitable for some patients with Marfan’s syndrome and others who would prefer to avoid anticoagulation. In conclusion, we consider the xenograft root inclusion method a simpler approach to radical root replacement when the native valve cannot be repaired.
References 1. Westaby S, Katsumata T, Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg 1997;64:1108–12. 2. Von Segesser LK, Renzelti E, Lachat M, et al. Aortic valve preservation in acute type A dissection. Is it sound? J Thorac Cardiovasc Surg 1996;111:381–91. 3. Fann JI, Glower DD, Miller DC, et al. Preservation of aortic valve in acute type A dissection complicated by aortic valve regurgitation. J Thorac Cardiovasc Surg 1991;102:62–75. 4. Miller DC, Mitchell RS, Oyer PE, et al. Independent determination of operative mortality for patients with aortic dissections. Circulation 1984;70(Suppl 1):153– 64. 5. Ergin MA, McCullough J, Galla JD, et al. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996;10:840–5. 6. Westaby S, Narasena N, Ormerod O, et al. Time related hemodynamic changes after aortic valve replacement with the Freestyle stentless valve. Ann Thorac Surg 1995;60:1633–9. 7. Bachet J, Goudot B, Teodori G, et al. Surgery of type A acute aortic dissection with gelatine-resorcine-formol biological glue. A twelve year experience. J Cardiovasc Surg 1990;31: 263–73. 8. Jin XY, Westaby S, Gibson R, et al. Left ventricular remodelling and improvement of Freestyle stentless valve haemodynamics. Eur J Cardiothorac Surg 1997;12:63–9. © 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;65:1450 –2
Ross Operation and Mitral Homograft for Aortic and Tricuspid Valve Endocarditis Alain Prat, MD, Olivier H. Fabre, MD, Andre´ Vincentelli, MD, Vincent Doisy, MD, and Ghatfan Shaaban, MD Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Re´gional et Universitaire de Lille, Lille, France
We report here a case of concomitant aortic and tricuspid valve endocarditis occurring in a 26-year-old woman 2 weeks after she had given birth by cesarean delivery. Preoperative transthoracic echocardiography revealed a previously undetected aorta–right atrium fistula, which at operation appeared to be congenital in origin. Surgical treatment consisted of aortic valve replacement with a pulmonary autograft, tricuspid valve replacement with a cryopreserved mitral homograft, and closure of the fistulous communication. The postoperative recovery was uneventful. (Ann Thorac Surg 1998;65:1450 –2) © 1998 by The Society of Thoracic Surgeons
S
everal surgical techniques have been reported for the treatment of infective endocarditis. These include the use of mechanical valves, bioprotheses, homografts, or pulmonary autografts. Although the choice of surgical technique remains debatable, it has been established that the radical excision of all infected tissue is a prerequisite for the successful treatment of the condition. We report here a case of aortic and tricuspid valve endocarditis associated with a congenital aorta–right atrium fistula treated with a Ross procedure and a cryopreserved mitral homograft. A 26-year-old woman was referred to the emergency department in April 1997 for acute dyspnea, weakness, and persistent fever. Her medical history revealed only an unexplored grade 2/6 systolodiastolic murmur and a cesarean delivery 15 days earlier. A physical examination of the patient disclosed a grade 4/6 systolic and diastolic murmur. A chest radiograph showed mild cardiomegaly, and the electrocardiogram showed a sinusal tachycardia. Transthoracic Doppler echocardiography revealed a massive aortic and tricuspid regurgitation, and several vegetations were observed on the posterior leaflet of the tricuspid valve. A fistula was noted with a continuous flow (. 4 m/s) between the noncoronary sinus and the right atrium. These data confirmed the diagnosis of acute
Accepted for publication Dec 3, 1997. Address reprint requests to Dr Prat, Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Regional Universitaire, 59037 Lille Cedex, France (e-mail: [email protected]).
0003-4975/98/$19.00 PII S0003-4975(98)00100-3