Aortic Valve Repair In Patients With Severe Bicuspid Valve Endocarditis
Oleg Orlov, Cinthia Orlov, Ryan Hoffman, Jonathan Gefen, Konstadinos Plestis.
Lankenau Medical Center, Philadelphia, PA, USA.
OBJECTIVE: Preserving the native aortic valve, when feasible, in cases of aortic valve endocarditis may be the best option in young patients. We demonstrate the feasibility of performing a complex aortic valve repair for aortic valve endocarditis via an upper partial sternotomy.
METHODS: This is a case of 31 y.o. male who presented with fever and lethargy. A CT scan of the abdomen showed multiple left renal infarcts. The blood cultures were positive for Streptococcus and a TEE showed a bicuspid aortic leaflet with echodensity, and severe aortic valve regurgitation. A six centimeter skin incision and an upper partial sternotomy, with extension to the right third intercostal space were performed. The right common femoral vein was exposed, heparin administered and the ascending aorta was cannulated using the Seldinger technique. A venous cannula was advanced into the superior vena cava using the Seldinger technique under TEE guidance. The aorta was cross-clamped and the heart arrested with a single dose of antegrade HTK-Custodiol solution.
RESULTS: The aorta was transected one cm above the Sinotubular junction and additional cardioplegia was given directly into the coronary artery ostia. The evaluation of aortic valve showed prolapse of the conjoined left and right leaflets with vegetations in the undersurface of the leaflet, as well as a perforation and vegetations of the noncoronary leaflet. All vegetations were excised. The perforation was cleaned and closed with a piece of Xenograft pericardium. The conjoined leaflets and then noncoronary cusp were plicated on the free edge for an effective height of nine mm. The root was circumferentially mobilized, and a Teflon felt ring was placed underneath the coronaries to establish an arterioventricular junction of 25 mm. The aortotomy and the chest were closed in a standard fashion. The postoperative TEE showed trace aortic valve insufficiency. The patient had an uneventful hospital course.
CONCLUSIONS: Repair of aortic valve in cases of endocarditis with the perforation of the cusp can be feasible in selective patients.
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