Surgical Treatment of Aortic and Mitral Valvular Endocarditis using a Single Aortic Homograft
Todd E. Horowitz, D.O., Tomas D. Martin, M.D.,
Yong G. Peng, M.D., Ph.D.
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
A 37-yr-old male with a history of IV drug abuse presented with a 3 week
history of bilateral lower extremity edema, intermittent fevers, night
sweats, and dyspnea. Physical exam was significant for a IV/VI diastolic
murmur. Transthoracic echocardiography revealed a vegetation on the aortic
valve with severe aortic insufficiency (AI), and a small vegetation on the
anterior leaflet of the mitral valve (AML) with moderate mitral
regurgitation (MR). The left ventricular ejection fraction was 25-30%.
Initial blood cultures were positive for Enterococcus fecalis. He was
treated with ampicillin and gentamycin for 3 weeks prior to surgical
intervention with subsequent sterile blood cultures.
Following anesthetic induction and placement of invasive monitors, a
transesophageal echo (TEE) examination confirmed severe AI with multiple
aortic valvular vegetations, as well as moderate MR with a perforation of
the AML.
After institution of cardiopulmonary bypass (CPB) and cooling to 28? C, the
aortic valve and root were resected, and 80% of the AML was resected without
disruption of the papillary muscles. A 22mm aortic homograft (Cryolife Inc.,
Kennesaw, GA) was chosen based on the TEE measurement at the aortic annulus.
The homograft had a large aortic curtain with AML tissue present, which was
retained in conjunction with the aortic homograft to reconstruct both the
aortic root and the damaged portion of the AML. Initial TEE evaluation of
the mitral repair prior to separation from CPB revealed severe MR due to
poor central leaflet coaptation. After re-cooling to 28? C, a mitral
annuloplasty was preformed with a #30 Carpentier-Edwards Physio ring
(Edwards LifeSciences, Irvine, CA). Following repair and after rewarming,
TEE revealed a normal functioning aortic homograft and excellent mitral
leaflet coaptation without MR. The procedure encompassed 189 minutes of
aortic cross-clamp and 276 minutes of total CPB time. The patient was weaned
from CPB without difficulty and had an uncomplicated postoperative course.
He was discharged 25 days after surgery due to social reasons.
Mitral valvular involvement is an occasional complication of aortic valve
infectice endocarditis (IE), presumably due to local extension of the
abscess cavity or from seeding of the AML by the AI jet. Aneurysm formation
of the AML and dissection of the AML have been reported, and conservative
medical management has been proposed as an acceptable alternative.
Perforation of the mitral valve leaflet, however, typically necessitates
surgical repair or replacement.
This case emphasizes the importance of intraoperative TEE to diagnose
intracardiac pathology, guide surgical treatment, and assess treatment
outcomes. This is the first reported case of primary aortic homograft use
for concomitant bi-valvular repair of aortic and mitral IE.
References
1. J Thorac Cardiovasc Surg 59:185-192, 1970.
2. J Cardiothorac Vasc Anesth 17: 271-72, 2003.
