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Urgent homograft aortic root replacement for aortic root abscess in infants and children
R Chaturvedi1, M de Leval, I D Sullivan
1Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK.
Insights
Early homograft aortic root replacement is a successful treatment for children with aortic root abscesses, even in critical conditions. This intervention offers a chance for survival and good functional outcomes in pediatric patients with severe infections.
Area of Science:
- Pediatric Cardiac Surgery
- Infective Endocarditis
- Aortic Root Abscess
Background:
- Aortic root abscesses are rare but life-threatening conditions in children.
- Diagnosis can be challenging due to non-specific presentations.
- Prompt surgical intervention is crucial for survival.
Purpose of the Study:
- To evaluate the outcomes of early homograft aortic root replacement in pediatric patients diagnosed with an aortic root abscess.
- To assess the feasibility and success of this surgical approach in critically ill children.
Main Methods:
- Retrospective review of patients with aortic root abscess between 1987 and 1997 at a tertiary referral center.
- Transthoracic echocardiography for diagnosis.
- Urgent homograft aortic root replacement with coronary reimplantation.
Main Results:
- Four out of five pediatric patients survived the initial surgery.
- Survivors achieved good functional status (New York Heart Association class I) and remained in sinus rhythm.
- Two survivors required subsequent reoperations for valve replacement.
Conclusions:
- Infective endocarditis should be suspected in children with severe sepsis or embolic events.
- Echocardiographic diagnosis of an aortic root abscess signifies critical infection and risk of hemodynamic collapse.
- Homograft aortic root replacement is a viable and successful strategy for managing aortic root abscesses in critically ill children.
Objective:
To assess the results of early homograft aortic root replacement in infants and children with an aortic root abscess.
Design:
Descriptive study of all patients with an aortic root abscess during 1987-97, identified by retrospective review of the echocardiographic and surgical registries.
Setting:
A tertiary referral centre.
Patients:
Five patients (age 0.6 to 13 years; two female) were identified with an aortic root abscess. Four had no known pre-existing congenital heart abnormality. Three had a misleading presentation and were referred to our hospital with non-cardiac diagnoses (fulminant hepatic failure; adult respiratory distress syndrome; cerebrovascular accident). The other two presented with septicaemia and a murmur, respectively. Blood cultures identified Staphylococcus aureus (n = 3) and Streptococcus pneumoniae (n = 2). Aortic root abscess was diagnosed by transthoracic echocardiography.
Interventions:
Homograft aortic root replacement with coronary reimplantation was performed urgently (median one day after diagnosis).
Results:
Four patients survived. The youngest died following multiorgan failure, multiple aortic fistulae, three valve involvement, and extensive tissue destruction preventing mitral valve replacement (S pneumoniae). Two of the four survivors have required further surgery: mitral valve replacement (0.3 years later), and pulmonary autograft replacement of the homograft (8.3 years later). All survivors remain in sinus rhythm and New York Heart Association functional class I.
Conclusions:
Infective endocarditis should be considered in any child with severe septicaemia or embolic phenomena. Echocardiographic diagnosis of an aortic root abscess indicates uncontrolled infection and impending haemodynamic collapse. Homograft aortic root replacement can be performed successfully in critically ill children with active infection.