Recurrent prosthetic valve endocarditis with aortic-ventricular disruption: a surgical challenge

Prosthetic valve endocarditis (PVE) after aortic valve replacement occurs infrequently but carries a high mortality rate, particularly with previous valved conduit root replacement or aortic root reconstruction (ARR). Infection can lead to paravalvular aortic root abscess, aorto-left ventricular disruption, and left ventricular pseudoaneurysm formation. Herein is presented a case series of aortic-left ventricular disruption and ventricular psuedoaneurysm secondary to PVE after previous aortic root replacement; the surgical approach and outcomes are discussed.

All patients who underwent cardiac valve surgery at The Methodist DeBakey Heart and Vascular Center between October 2008 and May 2011 were reviewed for cases of PVE with previous ARR with valved conduit and aortic root replacement. Five cases were identified, for whom the record review and follow up by clinic visit or telephone call after discharge was complete.

All patients survived surgical repair after complete redo aortic root excision and reconstruction with valved-conduit and coronary reimplantation. All patients underwent delayed sternal closure with mediastinal packing and, in four cases, definitive closure with omental flap. All patients were discharged and remain recurrence-free with the current management scheme.

Aortic left ventricular disruption from PVE after aortic root replacement with valved conduit can be managed successfully. The authors' strategy includes careful sternal entry with preparations for emergency bypass, complete excision of all infected material, redo total aortic root replacement and coronary reimplantation, initial open sternal management to control coagulopathy, and definitive closure with an omental transposition flap in a delayed fashion.