Treatment of prosthetic valve endocarditis by aortic valve neocuspidization using bovine pericardium

Treatment of prosthetic valve endocarditis by aortic valve neocuspidization using bovine pericardium Abstract A 78-year-old man who had undergone aortic valve and ascending aorta replacements presented with fever and was referred to our hospital. Blood culture revealed Gram-positive cocci, thus antibiotic therapy was started. Brain magnetic resonance imaging showed fresh cerebral infarction without cerebral haemorrhage or mycotic aneurysm. Transoesophageal echocardiogram revealed a vegetation that was attached to the right coronary cusp. The patient underwent successful aortic valve neocuspidization using glutaraldehyde-treated bovine pericardium. The postoperative course was uneventful with intravenous antibiotics administered for 6 weeks after confirming a negative blood culture, and no cardiac events occurred on follow-up by transthoracic echocardiogram 14 months postoperatively. Aortic valve neocuspidization, Bovine pericardium, Prosthetic valve endocarditis INTRODUCTION Aortic valve replacement remains the standard surgical treatment for prosthetic valve endocarditis (PVE) in many institutions. The clinical efficacy of aortic valve neocuspidization (AVNeo) using glutaraldehyde-treated pericardium has been reported [1]. We encountered a patient with prosthetic aortic valve endocarditis whom we have successfully treated by AVNeo without the further need for a prosthetic valve. CASE REPORT A 78-year-old man underwent bioprosthetic aortic valve replacement using a 23-mm-diameter Mosaic aortic porcine valve (Medtronic Inc., Minneapolis, MN, USA) and ascending aorta replacement using a 28-mm-diameter woven Dacron graft (J Graft Shield Neo, Junken Medical Co., Ltd, Chiba, Japan) 6 years earlier. The man presented with fever without elevation to 40.1 °C and tachypnoea and was referred to our hospital. The haemodynamic state of the patient was stable. However, he had cardiomegaly with a butterfly shadow on chest X-ray. He had no cardiovascular, thrombogenic or infectious risk factors. He was skiing before his condition deteriorated. He developed fever 2 days before admission. He had no leg paralysis on admission. Bilateral foot dyskinesis, not paralysis, was possibly due to hyperventilation. His leg arterial pulsation and ankle pressure were normal. On admission, the white blood cell count and C-reactive protein level were increased to 19 920/μl and 15.37 mg/dl, respectively. Blood culture revealed methicillin-sensitive Staphylococcus aureus, prompting the start of intravenous antibiotics. Cerebrovascular imaging by brain magnetic resonance imaging showed fresh cerebral infarction without cerebral haemorrhage or mycotic aneurysm. Transoesophageal echocardiogram revealed a 13-mm vegetation that was attached to the right coronary cusp of the prosthetic valve (Fig. 1A). Figure 1 View largeDownload slide Preoperative transoesophageal echocardiogram revealed a 13-mm vegetation that was attached to the right coronary cusp of the prosthetic valve (A, arrow). Postoperative Doppler transthoracic echocardiogram showed no aortic regurgitation (B, arrow). Figure 1 View largeDownload slide Preoperative transoesophageal echocardiogram revealed a 13-mm vegetation that was attached to the right coronary cusp of the prosthetic valve (A, arrow). Postoperative Doppler transthoracic echocardiogram showed no aortic regurgitation (B, arrow). As PVE was taken into paramount consideration, the patient underwent AVNeo using bovine glutaraldehyde-treated pericardium 17 days after admission as an elective surgery, because the patient suffered from acute cerebral infarction. The primary operative indications were aortic valve regurgitation and ascending aortic aneurysm. The operation was performed through a redo median sternotomy, and cardiopulmonary bypass was established via the native aortic arch and superior bicaval drainage after meticulous dissection. After achieving cardiac arrest, the ascending graft was opened, and the prosthetic valve was identified. Upon resection of the prosthetic valve cuff, purulent effusion flowed out from the inner side of the pannus. The pannus was orthotopically recognized at the right coronary cusp of the prosthetic valve, and PVE was diagnosed due to the infected pannus around the right coronary cusp. The aortic annulus was intact, and there was no destruction. After removal of the prosthetic valve including the infected pannus, the left ventricular outflow was thoroughly rinsed, and the glutaraldehyde-treated bovine pericardium (Edwards Lifesciences, Irvine, CA, USA) was prepared. The distance between each commissure was measured using a sizing apparatus. Three newly measured cusps were trimmed using a unique template from the bovine pericardium following the method of Ozaki et al. [1]. Finally, the 3 annular margins were running sutured with 4-0 polyvinylidene difluoride sutures (Asflex; Kono Seisakusho Co., Ltd, Chiba, Japan) in the following order: right, left and non-coronary cusps. Each commissural coaptation was fixed with 4-0 Asflex suture (Fig. 2). The cardiopulmonary bypass was weaned without difficulty. Figure 2 View largeDownload slide Operative image of the 3 reconstructed cusps. The commissural height was equally adjusted. LCC: left coronary cusp; NCC: non-coronary cusp; RCC: right coronary cusp. Figure 2 View largeDownload slide Operative image of the 3 reconstructed cusps. The commissural height was equally adjusted. LCC: left coronary cusp; NCC: non-coronary cusp; RCC: right coronary cusp. The postoperative course was uneventful with the intravenous administration of antibiotics for 6 weeks after confirming a negative blood culture. The coaptation length was preserved during the follow-up by transthoracic echocardiogram 14 months postoperatively with the peak and mean pressure gradients of 19 and 8 mmHg, respectively, without aortic regurgitation. DISCUSSION Although PVE is rare, it is associated with a high mortality and morbidity [2]. To achieve optimal outcome, the timing of surgical intervention in addition to the administration of antibiotics is an important consideration. In a review of the surgical treatments for PVE patients, it was reported that radical resection of all infected prosthetic valves and reconstruction of the heart and annuli using fresh autologous or glutaraldehyde-treated bovine pericardium provide the best chance of successfully treating the infection [3]. Since Ozaki et al. [1] developed the aortic valve reconstruction procedure using autologous pericardium and reported its excellent results, we have aggressively performed AVNeo for aortic valve pathologies in our institution. In this case, we took one of its benefits (i.e. less infectivity and biocompatibility) into consideration and performed surgical intervention. Moreover, because this patient was active for his age and an anticoagulation-free method was used, AVNeo was performed. If repeat aortic valve replacement with a biological aortic valve was performed, the same situation will possibly occur in the future. As a sufficient area of autologous pericardium could not be harvested because of its tight adhesion to the surrounding tissue, a glutaraldehyde-treated bovine pericardium was used as new aortic cusps. This tight adhesion, which prevented the removal of the previous vascular graft, was also thought to prevent the spread of the infection to that area. Regarding the survival rates of PVE patients between the biological valve group and the mechanical valve group, there was no significant difference according to a recent meta-analysis [4]. However, because reports comparing the results of AVNeo for PVE with others are lacking, further studies involving a large number of patients should be performed to further elucidate the efficacy and effectiveness of AVNeo for PVE. ACKNOWLEDGEMENTS We are indebted to Edward F. Barroga (http://orcid.org/0000-0002-8920-2607) for editing the article. Conflict of interest: none declared. REFFERENCES 1 Ozaki S, Kawase I, Yamashita H, Uchida S, Nozawa Y, Takatoh M et al.   A total of 404 cases of aortic valve reconstruction with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg  2014; 147: 301– 6. Google Scholar CrossRef Search ADS PubMed  2 Luciani N, Mossuto E, Ricci D, Luciani M, Russo M, Salsano A et al.   Prosthetic valve endocarditis: predictors of early outcome of surgical therapy. A multicentric study. Eur J Cardiothorac Surg  2017; doi:10.1093/ejcts/ezx169. 3 David TE. The surgical treatment of patients with prosthetic valve endocarditis. Semin Thorac Cardiovasc Surg  1995; 7: 47– 53. Google Scholar PubMed  4 Tao E, Wan L, Wang W, Luo Y, Zeng J, Wu X et al.   The prognosis of infective endocarditis treated with biological valves versus mechanical valves: a meta-analysis. PLoS One  2017; 12: e0174519. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Treatment of prosthetic valve endocarditis by aortic valve neocuspidization using bovine pericardium

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Abstract

Abstract A 78-year-old man who had undergone aortic valve and ascending aorta replacements presented with fever and was referred to our hospital. Blood culture revealed Gram-positive cocci, thus antibiotic therapy was started. Brain magnetic resonance imaging showed fresh cerebral infarction without cerebral haemorrhage or mycotic aneurysm. Transoesophageal echocardiogram revealed a vegetation that was attached to the right coronary cusp. The patient underwent successful aortic valve neocuspidization using glutaraldehyde-treated bovine pericardium. The postoperative course was uneventful with intravenous antibiotics administered for 6 weeks after confirming a negative blood culture, and no cardiac events occurred on follow-up by transthoracic echocardiogram 14 months postoperatively. Aortic valve neocuspidization, Bovine pericardium, Prosthetic valve endocarditis INTRODUCTION Aortic valve replacement remains the standard surgical treatment for prosthetic valve endocarditis (PVE) in many institutions. The clinical efficacy of aortic valve neocuspidization (AVNeo) using glutaraldehyde-treated pericardium has been reported [1]. We encountered a patient with prosthetic aortic valve endocarditis whom we have successfully treated by AVNeo without the further need for a prosthetic valve. CASE REPORT A 78-year-old man underwent bioprosthetic aortic valve replacement using a 23-mm-diameter Mosaic aortic porcine valve (Medtronic Inc., Minneapolis, MN, USA) and ascending aorta replacement using a 28-mm-diameter woven Dacron graft (J Graft Shield Neo, Junken Medical Co., Ltd, Chiba, Japan) 6 years earlier. The man presented with fever without elevation to 40.1 °C and tachypnoea and was referred to our hospital. The haemodynamic state of the patient was stable. However, he had cardiomegaly with a butterfly shadow on chest X-ray. He had no cardiovascular, thrombogenic or infectious risk factors. He was skiing before his condition deteriorated. He developed fever 2 days before admission. He had no leg paralysis on admission. Bilateral foot dyskinesis, not paralysis, was possibly due to hyperventilation. His leg arterial pulsation and ankle pressure were normal. On admission, the white blood cell count and C-reactive protein level were increased to 19 920/μl and 15.37 mg/dl, respectively. Blood culture revealed methicillin-sensitive Staphylococcus aureus, prompting the start of intravenous antibiotics. Cerebrovascular imaging by brain magnetic resonance imaging showed fresh cerebral infarction without cerebral haemorrhage or mycotic aneurysm. Transoesophageal echocardiogram revealed a 13-mm vegetation that was attached to the right coronary cusp of the prosthetic valve (Fig. 1A). Figure 1 View largeDownload slide Preoperative transoesophageal echocardiogram revealed a 13-mm vegetation that was attached to the right coronary cusp of the prosthetic valve (A, arrow). Postoperative Doppler transthoracic echocardiogram showed no aortic regurgitation (B, arrow). Figure 1 View largeDownload slide Preoperative transoesophageal echocardiogram revealed a 13-mm vegetation that was attached to the right coronary cusp of the prosthetic valve (A, arrow). Postoperative Doppler transthoracic echocardiogram showed no aortic regurgitation (B, arrow). As PVE was taken into paramount consideration, the patient underwent AVNeo using bovine glutaraldehyde-treated pericardium 17 days after admission as an elective surgery, because the patient suffered from acute cerebral infarction. The primary operative indications were aortic valve regurgitation and ascending aortic aneurysm. The operation was performed through a redo median sternotomy, and cardiopulmonary bypass was established via the native aortic arch and superior bicaval drainage after meticulous dissection. After achieving cardiac arrest, the ascending graft was opened, and the prosthetic valve was identified. Upon resection of the prosthetic valve cuff, purulent effusion flowed out from the inner side of the pannus. The pannus was orthotopically recognized at the right coronary cusp of the prosthetic valve, and PVE was diagnosed due to the infected pannus around the right coronary cusp. The aortic annulus was intact, and there was no destruction. After removal of the prosthetic valve including the infected pannus, the left ventricular outflow was thoroughly rinsed, and the glutaraldehyde-treated bovine pericardium (Edwards Lifesciences, Irvine, CA, USA) was prepared. The distance between each commissure was measured using a sizing apparatus. Three newly measured cusps were trimmed using a unique template from the bovine pericardium following the method of Ozaki et al. [1]. Finally, the 3 annular margins were running sutured with 4-0 polyvinylidene difluoride sutures (Asflex; Kono Seisakusho Co., Ltd, Chiba, Japan) in the following order: right, left and non-coronary cusps. Each commissural coaptation was fixed with 4-0 Asflex suture (Fig. 2). The cardiopulmonary bypass was weaned without difficulty. Figure 2 View largeDownload slide Operative image of the 3 reconstructed cusps. The commissural height was equally adjusted. LCC: left coronary cusp; NCC: non-coronary cusp; RCC: right coronary cusp. Figure 2 View largeDownload slide Operative image of the 3 reconstructed cusps. The commissural height was equally adjusted. LCC: left coronary cusp; NCC: non-coronary cusp; RCC: right coronary cusp. The postoperative course was uneventful with the intravenous administration of antibiotics for 6 weeks after confirming a negative blood culture. The coaptation length was preserved during the follow-up by transthoracic echocardiogram 14 months postoperatively with the peak and mean pressure gradients of 19 and 8 mmHg, respectively, without aortic regurgitation. DISCUSSION Although PVE is rare, it is associated with a high mortality and morbidity [2]. To achieve optimal outcome, the timing of surgical intervention in addition to the administration of antibiotics is an important consideration. In a review of the surgical treatments for PVE patients, it was reported that radical resection of all infected prosthetic valves and reconstruction of the heart and annuli using fresh autologous or glutaraldehyde-treated bovine pericardium provide the best chance of successfully treating the infection [3]. Since Ozaki et al. [1] developed the aortic valve reconstruction procedure using autologous pericardium and reported its excellent results, we have aggressively performed AVNeo for aortic valve pathologies in our institution. In this case, we took one of its benefits (i.e. less infectivity and biocompatibility) into consideration and performed surgical intervention. Moreover, because this patient was active for his age and an anticoagulation-free method was used, AVNeo was performed. If repeat aortic valve replacement with a biological aortic valve was performed, the same situation will possibly occur in the future. As a sufficient area of autologous pericardium could not be harvested because of its tight adhesion to the surrounding tissue, a glutaraldehyde-treated bovine pericardium was used as new aortic cusps. This tight adhesion, which prevented the removal of the previous vascular graft, was also thought to prevent the spread of the infection to that area. Regarding the survival rates of PVE patients between the biological valve group and the mechanical valve group, there was no significant difference according to a recent meta-analysis [4]. However, because reports comparing the results of AVNeo for PVE with others are lacking, further studies involving a large number of patients should be performed to further elucidate the efficacy and effectiveness of AVNeo for PVE. ACKNOWLEDGEMENTS We are indebted to Edward F. Barroga (http://orcid.org/0000-0002-8920-2607) for editing the article. Conflict of interest: none declared. REFFERENCES 1 Ozaki S, Kawase I, Yamashita H, Uchida S, Nozawa Y, Takatoh M et al.   A total of 404 cases of aortic valve reconstruction with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg  2014; 147: 301– 6. Google Scholar CrossRef Search ADS PubMed  2 Luciani N, Mossuto E, Ricci D, Luciani M, Russo M, Salsano A et al.   Prosthetic valve endocarditis: predictors of early outcome of surgical therapy. A multicentric study. Eur J Cardiothorac Surg  2017; doi:10.1093/ejcts/ezx169. 3 David TE. The surgical treatment of patients with prosthetic valve endocarditis. Semin Thorac Cardiovasc Surg  1995; 7: 47– 53. Google Scholar PubMed  4 Tao E, Wan L, Wang W, Luo Y, Zeng J, Wu X et al.   The prognosis of infective endocarditis treated with biological valves versus mechanical valves: a meta-analysis. PLoS One  2017; 12: e0174519. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 1, 2018

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