Left Ventricular-aortic Discontinuity Research Articles

Surgery for Bentall endocarditis: short- and midterm outcomes from a multicentre registry.

Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1-221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9-219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.

Surgical Treatment of Aortic Valve Endocarditis With Left Ventricular-Aortic Discontinuity

The periannular expansion of infection is a serious complication of infective endocarditis associated with high morbidity and mortality. The present study evaluates the results of aortic annular reconstruction in active infective endocarditis with left ventricular-aortic discontinuity. Left ventricular-aortic discontinuity was diagnosed by echocardiography in 25 (21 men, 4 female; mean age 60.2 ± 13.2 years) of 269 patients who underwent surgery for active native or prosthetic aortic valve endocarditis between January 2001 and October 2011. Seventeen (68%) and 8 (32%) patients had native and prosthetic valve endocarditis, respectively. Aortic root abscesses were radically debrided in all patients. The aortic annulus was reconstructed using autologous pericardium in 20 patients and a Dacron patch in 2. Isolated aortic valves were replaced with a bioprosthesis in 9 (36%) patients and a mechanical prosthesis in 13 (52%). Mechanical composite grafts were implanted in 3 (12%) patients. The mean follow-up was 29.1 ± 23.6 months and complete. Thirty-day mortality was 20% (n = 5). Survival at 3 years was 80% ± 8% with no significant difference between native and prosthetic valve endocarditis (log-rank, p = 0.69). Endocarditis did not recur during follow-up. Despite procedural progress, surgery for aortic valve endocarditis with left ventricular-aortic discontinuity remains associated with significant in-hospital mortality, but mid-term survival after the perioperative period is good. Annular reconstruction with a pericardial patch is technically safe.

Surgical treatment of aortic valve endocarditis with left ventricular – aortic discontinuity

Background The periannular expansion of infection is a serious complication of infective endocarditis associated with high morbidity and mortality. The present study evaluates the results of aortic annular reconstruction in active infective endocarditis with left ventricular-aortic discontinuity. Methods Left ventricular-aortic discontinuity was diagnosed by echocardiography in 25 (21 men, 4 female; mean age 60.2 ± 13.2 years) of 269 patients who underwent surgery for active native or prosthetic aortic valve endocarditis between January 2001 and October 2011. Seventeen (68%) and 8 (32%) patients had native and prosthetic valve endocarditis, respectively. Aortic root abscesses were radically debrided in all patients. The aortic annulus was reconstructed using autologous pericardium in 20 patients and a Dacron patch in 2. Isolated aortic valves were replaced with a bioprosthesis in 9 (36%) patients and a mechanical prosthesis in 13 (52%). Mechanical composite grafts were implanted in 3 (12%) patients. The mean follow-up was 29.1 ± 23.6 months and complete. Results Thirty-day mortality was 20% (n = 5). Survival at 3 years was 80% ± 8% with no significant difference between native and prosthetic valve endocarditis (log-rank, p = 0.69). Endocarditis did not recur during follow-up. Conclusions Despite procedural progress, surgery for aortic valve endocarditis with left ventricular-aortic discontinuity remains associated with significant in-hospital mortality, but mid-term survival after the perioperative period is good. Annular reconstruction with a pericardial patch is technically safe.

Surgical treatment for aortic periannular abscess/pseudoaneurysm caused by infective endocarditis

Delayed diagnosis or surgery sometimes causes more extensive destruction of aortic periannular abscess, or pseudoaneurysm, resulting in left ventricular-aortic discontinuity, particularly in patients with prosthetic valve endocarditis. The condition complicates the surgical procedures and causes worsening of short- and long-term outcomes. In-hospital mortality in patients with prosthetic valve endocarditis has been reported to be as high as 15-20 %, even at leading hospitals in the world. Contemporary modes of surgery for periannular abscess/pseudoaneurysm involve drainage of the cavity, radical debridement of necrotic tissue, annular reconstruction of the destroyed annulus, and root replacement using an optimal conduit. Radical debridement is of primary importance and is the universally accepted procedure, which frequently requires annular reconstruction using a pericardial patch. Conventional aortic valve replacement using a mechanical or stented biological valve, aortic valve replacement with translocation, aortic root replacement using an allograft, pulmonary autograft (Ross procedure), stentless biological valve, or a composite graft are conduits of choice. All things considered, allograft is believed to be the best conduit for a destroyed annulus because of better fit and its resistance to infection; however, recent reports have failed to confirm the superiority of allograft over other conduits in terms of long-term survival and freedom from reoperation/recurrence of infection. Short- and long-term outcomes have been studies for every type of conduit, but the selection of conduits for aortic root replacement is still controversial.

Aortic Root Replacement for Destructive Aortic Valve Endocarditis with Left Ventricular–Aortic Discontinuity

Aortic Root Replacement for Destructive Aortic Valve Endocarditis with Left Ventricular–Aortic Discontinuity

Aortic Root Replacement for Destructive Aortic Valve Endocarditis with Left Ventricular–Aortic Discontinuity

Destructive aortic valve endocarditis causes the development of left ventricular-aortic discontinuity. Our experience of aortic root replacement in patients with the left ventricular-aortic discontinuity is presented. Between 1999 and 2006, 8 patients (7 men, 1 woman) with left ventricular-aortic discontinuity underwent aortic root replacement in our institute. Their mean age was 56 years. Six patients were in New York Heart Association functional class III or higher. Four patients were diagnosed to have native valve endocarditis, and 4 had prosthetic valve endocarditis (previous aortic valve replacements in 2 patients, aortic root replacements in 2). Radical débridement of the aortic root abscess was performed in all patients, followed by reconstruction of the aortic annulus using autologous or xenogenic pericardium in 2 patients. Fibrin glue saturated with antibiotics was applied into the cavity in 5 patients. Aortic root replacement was achieved with pulmonary autograft (Ross procedure) in 4 patients and stentless aortic root xenograft in 3. One patient who had advanced liver cirrhosis underwent aortic valve replacement with a stentless xenograft by subcoronary fashion. No patients died during hospitalization or follow-up. Freedom from major adverse cardiac events was noted in 67% of the patients at 5 years. An excellent outcome can be achieved by radical exclusion of abscess in the cavity, followed by root replacement with viable pulmonary autograft or flexible stentless aortic root xenograft in patients with left ventricular-aortic discontinuity.

Allograft Aortic Root Replacement in Prosthetic Aortic Valve Endocarditis: A Review of 32 Patients

Background. This study was conducted to evaluate allograft aortic root replacement in the setting of complicated prosthetic valve endocarditis with extensive annular destruction.Methods. From January 1990 through March 1996, 32 patients diagnosed with complicated prosthetic valve endocarditis underwent allograft root replacement. Mean age was 58.3 ± 13.2 years; 23 patients were men. Mean preoperative New York Heart Association functional class was 3.4. Staphylococcus epidermidis (50%) and Enterococcus faecalis (19%) were the predominant causative microorganisms. Annular abscesses were found in 26 patients (81%), aortic-mitral discontinuity in 14 patients (43%), and left ventricular-aortic discontinuity in 11 patients (34%). A cryopreserved allograft was used in 31 patients (97%) and a fresh antibiotic-treated allograft was used in 1 patient (3%). Mean aortic cross-clamp time was 150 ± 29 minutes. Mean duration of the postoperative antibiotic treatment was 38.5 ± 11.8 days.Results. There were three operative deaths (9.4%); causes of death were multiorgan failure in 2 patients (6.2%) and low cardiac output in 1 patient (3.2%). Six patients (18%) had complete heart block (4 patients already before the operation), 3 patients (9.4%) had temporary respiratory insufficiency, and 1 patient (3.2%) needed temporary hemodialysis. Mean follow-up was 37.4 ± 22.4 months. Two late deaths occurred: 1 patient had recurrent endocarditis, leading to a false aneurysm, and died at reoperation; another patient died of lung cancer. Actuarial 5-year survival was 87.3% (70% confidence interval, 76.8% to 97.8%); actuarial 5-year freedom from recurrent endocarditis was 96.5% (70% confidence interval, 90.0% to 100%)Conclusions. Allograft aortic root replacement is a valuable technique in the complex setting of prosthetic valve endocarditis with involvement of the periannular region. Mortality and morbidity are low.(Ann Thorac Surg 1997;63:1644–9)

Treatment of Dissecting Aortic Root Aneurysm Complicated by Abscess after Valve Replacement

A 41-year-old man with a prosthetic aortic valve developed endocarditis with perivalvular leakage, formation of an abscess, and left ventricular-aortic discontinuity, 16 months after aortic valve replacement. Moreover, he developed a complicated huge dissecting ascending aortic aneurysm with thrombotic occlusion of the right coronary artery. Successful repair of this complicated aortic root lesion was achieved using a composite valved graft and employing coronary bypass grafting.

False Aneurysm of the Aortic Root and Right Ventricular Outflow Obstruction: An Unusual Complication of Surgically Treated Infective Endocarditis.

Aortic root abscess often complicates the course of aortic valve endocarditis. In severe cases, left ventricular-aortic discontinuity may occur, providing challenging technical problems for the surgeon. Moreover, surgical intervention sometimes takes place in a semi-emergency context, and the patches and prosthesis are sutured into friable tissues and subjected to high systemic pressures. Subsequently, paravalvular leaks and prosthesis dehiscence are not uncommon; postoperative false aneurysm of the aortic root is a much more unusual complication. We report one case of right ventricular outflow obstruction that occurred after surgical treatment of an aortic root abscess. Echocardiographic data were useful, but magnetic resonance imaging provided valuable information about the anatomic extent of the cavity. (ECHOCARDIOGRAPHY, Volume 13, January 1996)

Composite graft replacement of the ascending aorta and aortic valve: Late follow-up with intra-arterial digital subtraction angiography

Between 1979 and 1986, 30 patients underwent replacement of the aortic valve and ascending aorta by a composite graft, with aortic wrapping of the graft. Thirteen patients had annuloaortic ectasia; six had DeBakey type I dissection (five acute, one chronic); three had DeBakey type II dissection (one acute, two chronic); three had left ventricular-aortic discontinuity caused by prosthetic valve endocarditis; three had sinus of Valsalva aneurysms after previous aortic valve procedures; and two had atherosclerotic aneurysms. Three patients died (10%). The mean duration of follow-up was 54 months. Fifteen patients consented to be restudied by intra-arterial digital subtraction angiography; studies were performed 6 to 58 months (mean 25 months) after composite graft replacement. Two patients had pseudoaneurysms at the right coronary anastomosis, which were repaired successfully. One patient showed persistent dissection beyond the distal aortic anastomosis; no reoperation has been done. One patient had pulmonary edema. Emergency study and reoperation showed disruption of the proximal aortic anastomosis and right coronary anastomosis. Anastomotic dehiscence after composite graft replacement is potentially lethal. Follow-up by means of intra-arterial digital subtraction angiography is simple and highly accurate. We suggest that dehiscences may occur early in the postoperative period and that restudy may be appropriate within a few months after operation.

左室流出路‐大動脈基部不連続に対する外科治療

左室流出路‐大動脈基部不連続に対する外科治療

Repair of Left Ventricular-Aortic Discontinuity Complicating Endocarditis from an Aortic Valve Prosthesis

A case of bacterial endocarditis from an aortic valve prosthesis is described in which subannular pseudoaneurysm caused discontinuity of the aorta and left ventricle. Successful repair was accomplished using compound sponge-felt to bolster the left ventricular outflow tract and to obliterate the aneurysm.