CASE PRESENTATION:
A 57-year-old male presented to an outside hospital in the setting of
persistent fevers and chills for nearly two weeks following a dental
procedure. He had undergone an aortic root replacement with a mechanical
valve 9 years prior. He was diagnosed with severe, destructive
prosthetic valve endocarditis via echocardiography at the outside
hospital with blood cultures positive for S. sanguinis and was
subsequently transferred to our institution for tertiary level care and
consideration of high risk surgical intervention.
Upon arrival to our institution the patient was in first degree heart
block, though hemodynamically stable. Initially, transthoracic
echocardiogram (TTE) revealed an unstable root with evidence of aortic
valve “rocking” in addition to a large anechoic space concerning for
root abscess. Blood cultures were positive for S. sanguinis in
4/4 bottles and S. epidermidis in a single bottle. Coronary
computed tomography angiography (CCTA) was performed which revealed
multiple peri-aortic abscesses and mycotic pseudoaneurysmal collections
circumferentially surrounding the aortic root which communicated with
the graft lumen. There was extensive inflammatory phlegmon tracking into
the substernal space with focal areas of osteomyelitis in the adjacent
manubrium (Figure 1).
Transesophageal echocardiogram (TEE) was performed 24 hours after
admission, which revealed extensive, progressive destruction of the
entire circumference of the aortic annulus, with infection now involving
the aorto-mitral curtain and the entirety of the ascending aortic graft.
A comprehensive, multi-disciplinary team was brought together to
evaluate potential surgical treatment options for this patient given the
highly unlikely ability to reconstruct the root and aorto-mitral curtain
given the extreme destruction and need for extensive and thorough
debridement. The decision was made to proceed to the operating room to
evaluate the situation in real time, with plans for TAH should there be
insufficient remaining tissue to perform a reconstruction.
The patient was brought to the operating room for exploration and
definitive therapy. The aortic root was entirely dehisced, as was the
aorto-mitral curtain. Extensive pseudoaneurysm and infection was found
throughout the heart and the aortic graft. The decision was made to
proceed with debridement and TAH implantation.
TAH was implanted in the standard fashion without complication. The
patient’s chest was left open at the conclusion of the operation, and he
was brought back for washout and definitive closure on post-operative
day one. He was extubated on post-operative day three. The patient
currently remains in the hospital, where he is actively ambulating,
eating, and participating in therapies. Our committee plans to list the
patient for heart transplantation three months prior to TAH implantation
with no current barriers identified with respect to transplant listing.