Aortic Infective Endocarditis Research Articles

Gerbode defect resulting from Group B Streptococcus infective endocarditis: a case report

BackgroundGerbode defect is an unusual abnormal communication between the left ventricle and the right atrium and is a serious complication of aortic infective endocarditis. Group B Streptococcus is an uncommon cause of infective endocarditis and has a markedly destructive effect on valvular tissue. Acute fistulation between the left ventricle and the right atrium associated with this form of infective endocarditis is a life-threatening, aggressive complication that often requires urgent surgical intervention. However, the identification of actual communication is often extremely difficult. Herein, we describe an unusual case of Gerbode defect resulting from Group B Streptococcus infective endocarditis and discuss the issues surrounding such a rare cardiac defect and such an infection.Case presentationA 60-year-old man with underlying uncontrolled diabetes mellitus underwent endoscopic retrograde biliary drainage for acute cholangitis. On the 10th postoperative day, the patient developed multiple acute cerebral embolisms. Transthoracic echocardiography demonstrated severe aortic regurgitation and a large mobile vegetation near the tricuspid annulus. No obvious fistula between the left ventricle and the right atrium could be demonstrated. The blood culture examination was positive for Group B Streptococcus. The patient was diagnosed with Group B Streptococcus infective endocarditis, and antibiotic therapy was initiated. Transesophageal echocardiogram performed after referral to our hospital confirmed detachment of the right coronary cusp of the aortic valve from the annulus and an abnormal cavity immediately below the right coronary cusp. Color Doppler imaging finally revealed systolic blood flows from the left ventricle into the right atrium through the cavity. Therefore, we diagnosed the patient with Gerbode defect resulting from Group B Streptococcus infective endocarditis. In addition to aortic valve replacement, defect closure and left ventricular outflow tract repair were successfully performed urgently for severely complicated and uncommon infective endocarditis. The patient was uneventfully discharged without any complications.ConclusionsWe reported successful surgical treatment of unusual active IE and Gerbode defect caused by GBS. Careful preoperative echocardiographic work-up is imperative for accurate early diagnosis and successful repair.

Aortic valve replacement with rapid-deployment bioprosthesis in case of infective endocarditis: a literature review.

Recently, the use of rapid deployment (RD) aortic valve prostheses has been introduced for the treatment of aortic valve replacement (AVR), showing excellent hemodynamic performances.According to these data, some groups have proposed new RD valves as an alternative solution in the case of infective aortic endocarditis (IAE) to reduce the use of foreign materials, and the manipulation of the annulus.The aim of this review is to report the results of early clinical experiences with the use of RD bioprostheses in the case of IAE, in order to discuss technical and clinical aspects of this emerging strategy to better elucidate its advantages and limitations as a potential therapeutic solution. An in-depth search of PubMed from January to March 2023 was performed. English-language articles were selected independently by authors following the criteria in order to consider all available experiences (full papers, case reports, and case series) that have investigated the use of RD in case of IAE. The use of rapid deployment bioprosthesis represents a bailout strategy in case of severe aortic valve endocarditis and should be evaluated with caution in selected cases. This review collects the first, initial, and pioneering experiences of the use of the RD prosthesis in case of infective endocarditis, particularly when the fragility of the annular tissues precludes a secure anchoring of sutured prostheses.The reduced use of foreign materials by minimizing the number of stitches, the reduced cardiopulmonary bypass (CPB) and aortic cross-clamp times, and the excellent hemodynamic performances associated with the use of RD bioprosthesis represent the most important advantages that could justify their use in the setting of aortic valve endocarditis. Although there are few anecdotal experiences, surgical aortic valve replacement with the use of RD represents an emerging strategy in case of aortic valve endocarditis. Its advantages, pros, and cons are under debate, and robust clinical trials are needed to demonstrate its safety and efficacy.

Cardiac Device-related Infective Endocarditis and Retrosternal Abscess Treated with Percutaneous Lead Extraction and Antimicrobials: A Case Report.

An 85-year-old man with a history of 2 open-heart surgeries (for aortic regurgitation and infective endocarditis [IE]) and pacemaker implantation for bradycardic atrial fibrillation presented with a fever. Transesophageal echocardiography revealed a pacemaker lead vegetation. Computed tomography showed a retrosternal abscess. He was diagnosed with acute heart failure and IE. Given the high surgical risk due to his age, acute heart failure, and surgical history, we decided against cardiac surgery. After lead extraction, a leadless pacemaker was inserted, and antimicrobial therapy was administered. The patient was discharged on day 48, highlighting a strategy for managing complex cardiac device-related IE.

A surgically salvaged case: emergency Root-Commando procedure for infective endocarditis and chronic dissecting aneurysm of the sinus of Valsalva.

The Commando procedure for infective endocarditis is a high-risk intervention. However, infective endocarditis involving the intervalvular fibrosa is fatal in the absence of surgery. A 41-year-old man with no medical history visited a doctor with chest pain and dyspnoea. Ascending aortic dissection and vegetation on the mitral valve were noted on echocardiography, so he was transferred to our hospital. The diagnosis was dissecting aneurysm of the sinus of Valsalva and acute heart failure due to aortic regurgitation, mitral regurgitation and infective endocarditis. We decided on emergency surgery. Intraoperatively, we confirmed abscess extending to the left atrial roof and destruction of the intervalvular fibrosa, so we performed the Root-Commando procedure. The patient was saved and discharged 47 days after transfer to our hospital through the reoperation on postoperative day 30.

The Bacterial Profile of Aortic Infectious Endocards: Experience of the Cardiology Department, Mohammed VI University Hospital of Marrakech, Morocco

Introduction: Infective endocarditis is defined as infection of a native or prosthetic heart valve, endocardial surface, or cardiac device. The causes and epidemiology, as well as the microbiology of the disease have evolved over the last few decades with the doubling of the average age of patients and an increased prevalence in patients with indwelling cardiac devices. Patients and Methods: This is a retrospective study, including all subjects over 20 years of age who presented with infective endocarditis of the aortic valve, hospitalized between January 2019 and December 2022, in the Department of Cardiology and Vascular Diseases at ERRAZI Hospital-Mohammed VI University Hospital in Marrakech. Clinical, paraclinical and therapeutic data were collected for each case using an exploitation form. Results: Over the study period, 46 patients had presented with aortic positional AR, with a sex ratio that was equal to 1.8. The mean age of the patients was 43±12.5 years. Endocarditis on aortic prosthesis was found in 15%. The valves were rheumatic in 85%. The presumed portal of entry was cutaneous in 45%, oral and ENT in 33%, urinary in 15%, and digestive in 7%. In our series, 21 out of 26 patients presented a biological inflammatory syndrome. At least one or more blood cultures were positive in 38% of cases. Coagulase-negative Staphylococcus was the most common germ in aortic infective endocarditis, found in 40% of positive blood cultures. All the patients in our series had received a combination of broad-spectrum intravenous antibiotic therapy, initially probabilistic, taking into consideration the portal of entry. Adapted after antibiogram results. The evolution during the hospitalization, was marked by an improvement of the clinical state in only 12%, a perioperative death in 38%, and a worsening of the clinical state in 50%, with an average duration of hospitalization of 14 days. In our series, 60% of the patients with positive blood cultures died, whereas there was 75% survival in the group with negative blood cultures. Conclusion: Infective endocarditis is a serious disease because of its high morbidity and mortality. Despite improvements in diagnostic testing, antimicrobial therapy, and surgical intervention, changes in the epidemiology of IE, including the increase in healthcare-associated infections and the virulence of staphylococcus aureus as the causative organism, increase the risk of complications and death in the acute phase of IE. Action must be taken to prevent infective endocarditis, especially in this rheumatically endemic area.

Ischemic Stroke with Aortic Infective Endocarditis Complicated by Pulmonary Artery Abscess

The initial lesions of infective endocarditis (IE) are mainly valvular, but sometimes may cause other cardiac or extracardiac complications. Cerebral involvement is the most frequent site of extracardiac complications caused by IE. They might be the mode of revelation in 10 to 20% of patients. These complications increase morbidity and mortality. We report the case of a patient with IE complicated by a fistulised abscess in the pulmonary artery leading to a stroke.

Annals for Hospitalists Inpatient Notes - Clinical Pearls-Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis in Persons Who Inject Drugs.

Web ExclusivesMarch 2023Annals for Hospitalists Inpatient Notes - Clinical Pearls—Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis in Persons Who Inject DrugsLarry M. Baddour, MD and Daniel C. DeSimone, MDLarry M. Baddour, MDDivision of Public Health, Infectious Diseases and Occupational Health, Departments of Medicine and Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic Rochester, Rochester, Minnesota (L.M.B., D.C.D.).Search for more papers by this author and Daniel C. DeSimone, MDDivision of Public Health, Infectious Diseases and Occupational Health, Departments of Medicine and Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic Rochester, Rochester, Minnesota (L.M.B., D.C.D.).Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-0241 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail A 26-year-old woman presented to the emergency department for fever and chills of 5 days duration. Her recent history included injection drug use of both heroin and cocaine, and she had shared paraphernalia on 2 occasions over a weekend party. She was ultimately diagnosed with bilateral (tricuspid and aortic) infective endocarditis (IE) due to methicillin-susceptible Staphylococcus aureus. After an 8-day hospital stay, she was transitioned to outpatient parenteral antimicrobial therapy (OPAT) and buprenorphine (which had been initiated on day 2 of the hospital stay), with outpatient follow-up by addiction medicine and infectious diseases. A peripherally inserted central catheter (PICC) was ...

POSSIBLE CORONARY SYNDROME IN A CHILD WITH AORTIC ENDOCARDITIS DURING CARDIAC SURGERY.

Infective endocarditis (IE) in children it is serious condition and has a hospital mortality rate 10-20 % with medical treatment. Although, surgical management is the last chance for severely ill patients and has been associated with a mortality rate of 50 %. This is a case report of a child 10 years old with aortic IE who developed coronary syndrome intraoperatively. A 10-year-old boy with history of aortic valve repair 6 years ago was recently diagnosed with aortic endocarditis. He was transferred to the cardiac center for treatment. Clinically, he was unwell, pale and complaining of chest pain days before the surgery. He was admitted with electrocardiography changes, ST depression DI-II, V5 and V6.Echocardiogram revealed a mobile mass on the aortic valve which prolapsed into the left ventricle during diastole causing severe aortic regurgitation. Heparin anti-coagulation was instituted upon arrival. He received meropenem and teicoplanin for 5 days and was transfused before surgery. He underwent urgent aortic replacement due to the mobile mass on the aortic valve, unresolved EKG changes and increasing heart failure. Intraoperatively during repeat sternotomy and lysis of adhesions he developed worsening coronary syndrome (increase of previous ST depression DI-II and more III). Hypotension and bradycardia developed which did not responded to atropine. Pulseless electrical activity ensued, and open cardiac massage and paediatric advance life support was performed for 25 minutes before establishing cardiopulmonary by-pass (CPB). During CPB he developed increasing of metabolic acidosis, lactate and decreased of urine output less than 0.9 ml/kg/h. Aortic valve replacement with 19 mm mechanical valve was done during hypothermia 28 degrees. Following release of the cross-clamp no electrical activity occurred and was connected to the pacemaker VVI for 3 hours and worsening of lactic acidosis (lactate 17),urine output decreasing and creatinine increasing. Disconnection from CPB was done and the patient died. Surgery was performed in a resource restricted low- and middle-income country Figure 1.Mid esophageal AV Long Axis View (ME AV LAX) 110 degrees: significant size mass attached to right size of aortic valve, moving, creating severe insufficiency. Figure 2.Deep Transgastric Long Axis view (Deep TG LAX) 120 degrees, showed opening of aortic valve, thickened and dysplastic. Significant jet from aortic regurgitation with significant size vegetation and showed LV severe dilated with moderate to severe impairment.

Invasive Coronary Angiography in Patients with Native or Prosthetic Aortic Valve Endocarditis.

Invasive coronary angiography (ICA) is essential to detect significant coronary artery disease (CAD) but is generally not recommended in patients with infective aortic valve endocarditis. This study aimed to evaluate the risks and benefits of preoperative ICA in patients before aortic valve replacement. Between March 2008 and September 2020, 232 patients were surgically treated for infectious endocarditis of the aortic valve. Sixty-seven (29%) of them underwent preoperative diagnostic ICA and were compared with the patients without preoperative ICA. We collected their baseline characteristics, including the neurological status, previous cardiac surgical procedures, and reviewed the preoperative echocardiograms and the ICA data. The intraoperative data and clinical outcomes after ICA and after surgery were evaluated. ICA revealed a CAD in the majority of our patients (n = 36; 54%): One-vessel disease n = 19 (28%), two-vessel disease n = 6 (9%), and three-vessel disease n = 11 (16%). We observed no adverse events following preoperative diagnostic ICA, particularly no thromboembolic complications, including stroke, visceral, or lower body ischemia were detected. During surgical aortic valve replacement, concomitant coronary artery bypass grafting was performed in 20 patients (30%). In patients with preoperative ICA, postoperative in-hospital mortality was significantly lower (n = 8 [12%] vs. n = 30 [18%]; p < 0.001), while the incidence of postoperative bleeding was higher (n = 18 [27%] vs. n = 22 [13%]; p = 0.022). The new-onset stroke incidence was 5% in each group. Taking a multidisciplinary team approach, ICA is safe in selected patients with aortic valve infectious endocarditis with no adverse clinical outcomes, but significant clinical implications.

Repair of coronary artery ostium with a ring-shaped bovine pericardial patch.

As an approach to coronary artery ostial injury in type A aortic dissection and infective endocarditis, we describe a technique of coronary ostial repair using a ring-shaped bovine pericardial patch. The inner and outer rims of the patch were sutured to the involved coronary ostium (to close the ostial tear) and to the aortic wall (to cover the sinus), respectively. Four patients were successfully managed and computed tomographic coronary arteriogram at follow-up showed patent coronary ostia and arteries. The favourable preliminary results imply that this technique is a simple, safe and effective approach to coronary ostial repair in patients with type A aortic dissection or infective endocarditis.

Infective Endocarditis Complicated by Fistulized Pseudoaneurysm in the Left Ventricle: Case Report

This is a case report of a 39-year-old patient with a history of recurrent angina since her childhood, who was diagnosed with a endocarditis complicated by pseudoaneurysm. The pseudoaneurysm is a rare complication. We report the case of a pseudo aneurysm of the right coronary sinus fistulized into the left ventricle complicating a surgically treated aortic infective endocarditis.

Unexpected clinical case of Pasteurella multocida infectious endocarditis in a patient with iv drug abuse: why epidemiological history matters

Right-sided lesions caused by staphylococci are the most common clinical entity of infectious endocarditis (IE) among iv drug abusers. But some aspects of the epidemiological history are critical in terms of early detection of uncommon pathogens. We describe a clinical observation of native aortic valve IE caused by Pasteurella multocida in a 37-year-old female with a history of heroin addiction, alcohol abuse and liver cirrhosis.She presented herself at our hospital with acute fever, chills, subconjunctival petechial hemorrhages, traces of scratches on the hands, splenomegaly, peripheral edema, elevated WBC and inflammatory serum markers. Initial transthoracic echocardiography was negative, but the patient was put on oxacillin for suspected right-sided IE. The transesophageal echocardiography revealed vegetation on noncoronary leaflet of aortic valve. Blood culture was positive with the growth of P. multocida in 4/4 samples.On detailed questioning, a close domestic contact with cats was revealed. Oxacillin was switched to meropenem and tigecycline with a prompt clinical response. The P. multocida isolate was found to be susceptible to penicillins, so the patient was discharged after 3 weeks with recommendations to take amoxicillin for up to 4 weeks. At 3 and 6 months follow-up there were no signs of IE relapse revealed. P. multocida is a rare causative agent of IE. In our case, this pathogen was identified in a patient with injection drug use, where such etiology is not usually assumed. The close contact with cats was not taken into account, which caused late diagnosis and delayed therapy.

Aortic Prosthetic Valve Endocarditis: Analysis of The Society of Thoracic Surgeons Database

BackgroundThis study sought to characterize the current US experience of aortic prosthetic valve endocarditis (PVE) compared with native valve endocarditis (NVE). MethodsThe Society of Thoracic Surgeons Database was queried for entries of active aortic infective endocarditis (IE). Two analyses were performed: (1) trends of surgical volume and operative mortality (2011-2019); and (2) descriptive and risk-adjusted comparisons between PVE and NVE (2014-2019) using multivariable logistic regression. ResultsFrom 2011 to 2019, there was a yearly increase in the proportion of PVE (20.9% to 25.9%; P < .001) with a concurrent decrease in operative mortality (PVE, 22.5% to 10.4%; P < .001; NVE, 10.9% to 8.5%; P < .001). From 2014 to 2019, active aortic IE was identified in 9768 patients (NVE, 6842; PVE, 2926). Aortic root abscess (50.1% vs 25.2%; P < .001), aortic root replacement (50.1% vs 12.8%; P < .001), homograft implantation (27.2% vs 4.1%; P < .001), and operative mortality (12.2% vs 6.4%; P < .001) were higher in PVE. After risk adjustment, PVE (odds ratio [OR], 1.5; 95% CI,1.16-1.94; P < .01), aortic root replacement (OR, 1.49; 95% CI,1.15-1.92; P < .001), Staphylococcus aureus (OR, 1.5; 95% CI,1.23-1.82; P < .001), and unplanned revascularization (OR, 5.83; 95% CI,4.12-8.23; P < .001) or mitral valve surgery (OR, 2.29; 95% CI,1.5-3.51; P < .001) correlated with a higher operative mortality, whereas prosthesis type (P = .68) was not an independent predictor. ConclusionsIE in the United States has risen over the past decade. However, operative mortality has decreased for both PVE and NVE. PVE, extension of IE requiring aortic root replacement, and additional unplanned surgical interventions carry an elevated mortality risk. Prosthesis selection did not affect operative mortality.

Epidemiological aspects of the aortic valve pathology

The dynamics of the structure of aortic valve pathology over the thirty-year (19912020) period of operation of the cardiac surgery hospital of the first department and the clinic of surgery for advanced training of doctors of the Military Medical Academy named after S.M. Kirov is evaluated. 849 cases of aortic valve replacement were retrospectively studied (626 (74%) men, 223 (26%) women). The average age of the patients was 51.8 9.7 years. It was established that the main causes of aortic valve damage were rheumocarditis, calcified aortic stenosis, infectious endocarditis and congenital heart disease in the form of a bicuspid aortic valve. A significant decrease in the incidence of rheumatism as a cause of aortic malformation was revealed from 36% in the period from 1991 to 2000 to 13% in the period from 2011 to 2020. The frequency of calcified aortic stenosis during this period, on the contrary, increased from 30% to 70%, respectively. At the same time, the relationship between the increase in life expectancy of the population of the Russian Federation and the frequency of occurrence of calcified aortic stenosis is traced. This is due to a long asymptomatic period that characterizes the natural course of this pathology, as a result of which the clinical manifestations of this pathology manifest, as a rule, only in old age. During the study period, an increase in the average age of patients who needed aortic valve replacement was also noted. If in the last decade of the twentieth century. it was 41.5 years, then in the period from 2011 to 2020, the average age of patients who needed aortic valve replacement increased to 61.5 years. Thus, over the past thirty years, there has been a significant change in the structure of the pathology of the aortic valve. Calcified aortic stenosis has become the most common cause of prosthetics of aortic malformation, against the background of a significant decrease in the frequency of rheumatic genesis of aortic valve damage.

1313 Unusual Supraannular Aortic Root Intimal Tear in a Patient with Severe Aortic Regurgitation

Abstract We present an extremely rare case of occult supraannular aortic root intimal tear in a patient presenting with acute severe aortic regurgitation (AR) and a previously undiagnosed bicuspid aortic valve. A 41-year-old Africo-Carribean female presented to the emergency department with acute pulmonary oedema and increasing dyspnea on exertion. She had been treated empirically with antibiotics for a chest infection. Initial concerns were either aortic dissection or infective endocarditis. Transthoracic echocardiography (TTE) demonstrated a normal size left ventricle with hyperdynamic systolic function and severe AR. The patient was transferred to a tertiary cardiothoracic surgical centre for urgent surgical treatment in view of haemodynamic instability and acute AR. A gated computed tomography aortogram identified pulmonary oedema with an asymmetrically dilated aortic root (maximal diameter 45 mm). Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and prompted Bentall procedure with mechanical aortic valve. After median sternotomy and initiation of cardiopulmonary bypass, a supraannular aortic intimal tear starting from the right coronary cusp/noncoronary cusp commissure was found with no extension into the aorta. The aortic valve was bicuspid and severe AR not amenable to repair was found. Bentall procedure was performed using the 23/26mm Carbomedics Carbo Seal Valsalva composite graft (Sulzer Carbomedics Inc, Austin, TX, USA). The patient was discharged on the 7th postoperative day in sinus rhythm. At 30-day clinical follow-up she was symptom free with a satisfactory TTE.

Should We Quantify Valvular Calcifications on Cardiac CT in Patients with Infective Endocarditis?

Background: Evaluate the impact of valvular calcifications measured on cardiac computed tomography (CCT) in patients with infective endocarditis (IE). Methods: Seventy patients with native IE (36 aortic IE, 31 mitral IE, 3 bivalvular IE) were included and explored with CCT between January 2016 and April 2018. Mitral and aortic valvular calcium score (VCS) were measured on unenhanced calcium scoring images, and correlated with clinical, surgical data, and 1-year death rate. Results: VCS of patients with mitral IE and no peripheral embolism was higher than those with peripheral embolism (868 (25–1725) vs. 6 (0–95), p < 0.05). Patients with high calcified mitral IE (mitral VCS > 100; n = 15) had a lower rate of surgery (40.0% vs.78.9%; p = 0.03) and a higher 1-year-death risk (53.3% vs. 10.5%, p = 0.04; OR = 8.5 (2.75–16.40) than patients with low mitral VCS (n = 19). Patients with aortic IE and high aortic calcifications (aortic VCS > 100; n = 18) present more frequently atypical bacteria on blood cultures (33.3% vs. 4.8%; p = 0.03) than patients with low aortic VCS (n = 21). Conclusion: The amount of valvular calcifications on CT was associated with embolism risk, rate of surgery and 1-year risk of death in patients with mitral IE, and germ’s type in aortic IE raising the question of their systematic quantification in native IE.

Surgical management of divided atrial chambers.

The morphological variations when one, or both, of the atrial chambers is subdivided, are many and varied. We sought to address clinical presentations, potentially misdiagnosed cases, diagnostic modalities, surgical approaches, and outcomes of this "family" of uncommon lesions. A total of 193 published investigations were synthesized. Diagnostic information was provided by clinical presentation, and multimodality imaging studies. Almost three-quarters of patients with divided atrial chambers present during infancy with severe pulmonary hypertension and cardiac failure. Associated cardiac and extra-cardiac defects are present in between half and nine-tenths of cases. Acquired division of the left atrium has been reported after the Fontan operation, orthotopic cardiac transplantation, and complicated aortic valvar infective endocarditis. Surgery under cardiopulmonary bypass remains the definitive treatment. Balloon dilation may be considered in anatomically compatible variants in the setting of cardiac failure and pregnancy as a bridge todefinitive treatment. Overall, mortality has been cited between nil to 29%. Presentation during infancy, associated congenital anomalies, pulmonary hypertension, and surgery in the previous era, have been the reported causes of death. The operative survivors have long-term favourable outcomes, with near normal cardiac dimensions and low risk of recurrence. While asymptomatic patients with division of the right atrium do not need treatment, surgical resection of the dividing partition under cardiopulmonary bypass is recommended in symptomatic patients with complex anatomy, the spinnaker malformation, or associated cardiac anomalies. Balloon dilation may be considered in uncomplicated patients with less obstructive lesions. Hybrid intervention and endoscopic robotic correction also have been performed. Resection of the dividing shelf allows the survivors to regain near normal dimensions with a low risk of recurrence. We submit that an increased appreciation of the anatomic background to division of the atrial chambers will contribute to improved surgical management.

Unicuspid aortic valve and infective endocarditis

A 34-year-old woman with a two-week history of fever presented to the emergency department. Blood tests revealed leukocytosis and elevated C-reactive protein levels. A systolic cardiac murmur was d...

Subtle aortic dissection in a patient with severe aortic regurgitation and undiagnosed bicuspid aortic valve: A case report with a literature review

A subtle aortic dissection can be challenging to detect despite the availability of multiple diagnostic modalities. Whilst rare, the inability to detect this variant of aortic dissection can lead to a dismal prognosis. We present an extremely rare case of a subtle aortic dissection with supra-annular aortic root intimal tear and acute severe aortic regurgitation in a patient with a bicuspid aortic valve. Case report and literature review conserning subtle aortic dissection is provided. Initial concerns were either aortic dissection or infective endocarditis. Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and a Bentall procedure with a mechanical aortic valve was performed. Our case along with the review of current literature emphasizes that current imaging techniques may be inadequate for diagnosis of this rare variant of aortic dissection.

Contemporary Ross procedure outcomes: medium- to long-term results in 214 patients.

Our goal was to present 2 decades of our experience with the Ross procedure and its sequential modifications, adopted since 2010, to improve the reoperation rate. We performed a single-centre, retrospective review of database information and medical notes about the implantation technique: the freestanding root. We compared era 1 (1997-2009) and era 2 (2010-2019). Between 1997 and 2019, a total of 214 Ross procedures were performed (71% men, median age 24 years) [interquartile range (IQR) 15-38]. Of these, 87% had various forms of congenital-dysplastic aortic valves. The median cross-clamping and bypass times were 173 (IQR 148-202) and 202 (IQR 182-244) min. The median postoperative stay was 6 days (2-77). Thirty-day mortality was 0.5%. The median follow-up time was 8.2 years (IQR 3.9-13.2). Survival at 10 and 20 years was 97% and 95%; freedom from greater than moderate aortic regurgitation or aortic valve intervention was 91% and 80%; and 93% of the patients were in New York Heart Association functional class I. Twenty (21%) patients operated on during era 1 and 6 (9%) during era 2 underwent autograft reoperations. The median follow-up time was 14.3 (IQR 11.5-17.4) and 4.8 (IQR 2.5-7) years. Freedom from autograft reoperation was 87% and 69% at 10 and 20 years, with no significant difference between eras. Freedom from homograft reoperation was 96% and 76% at 10 and 20 years. The presence of aortic regurgitation, infective endocarditis and era 1 were predictors of autograft reoperation. Male gender and era 1 were predictors of neoaortic root dilatation. The contemporary modified Ross procedure continues to deliver excellent results and should remain part of the strategy to treat children and young adults requiring aortic valve replacement.