How to repair an acquired Gerbode defect using an aortic root xenograft

A 74-year old female patient presented with a 3-week history of fever, general weakness, and later developed complete heart block. On admission, the patient was febrile (temperature of 39°C) and tachypnoeic (respiratory rate of 29/min) with oxygen saturation of 95% on 2 L of oxygen. Her heart rate was 60 beats/min (VVI pacing), arterial blood pressure was 135/60 mm Hg and the Glasgow Coma Scale was 15. On chest auscultation, she had a harsh systolic murmur over her left precordium and bilateral rales. Blood tests demonstrated moderate anemia (hemoglobin of 95 g/L), leucocytosis (white blood cell count of 13.13 x 10^9/L), hypoalbuminemia (albumin concentration of 18 g/L), normal liver function tests and creatinine clearance of 45 ml/min. Computed tomography aortography demonstrated an irregular mass arising from the aortic root that extended into the right atrium (RA) and a fistulous tract (the Gerbode defect) between the left ventricular outflow tract (LVOT) and the right ventricle (RV). Transoesophageal echocardiography showed large vegetation in the RA and left to right cardiac shunt through the Gerbode defect from the LVOT to the RA and the RV. Using cardiopulmonary bypass, the patient underwent resection of the aortic cusps, debridement of the aortic root, septal and anterior leaflets of the tricuspid valve, and the membranous septum. The Gerbode defect was closed with an autologous pericardial patch, then a sliding annuloplasty of the septal leaflet of the tricuspid valve was performed. Finally, the aortic root was replaced with a 23 mm Freestyle xenograft.