A 71-year-old female patient was admitted under cardiology due to progressive dyspnea, NYHA Class III, flu-like symptoms and night sweats. From the past medical history, the patient was in end-stage renal failure under hemodialysis and was submitted to an AVR with a tissue valve (21 mm St Jude Trifecta) 3 years prior to the current admission. During work up, Staphylococcus aureus was isolated from the blood cultures and the patient was started on the daptomycin and rifampicin according to microbiology.
Transesophageal echocardiography (TEE) revealed moderate stenosis of the previous prosthesis with paravalvular leak, preserved ejection fraction (EF) and the presence of an abscess cavity extending from the non- and the left coronary cusp to the roof of the left atrium. Furthermore, there were multiple vegetations in the right atrium (Fig. 1a, b) with a left ventricular outflow tract (LVOT)-to-right atrium fistula. A partial defect of the AMC reaching the anterior mitral valve leaflet associated with moderate mitral regurgitation was noted. The patient was referred for urgent surgery.
After redo sternotomy and arrest of the heart, transverse aortotomy revealed dehiscence of the aortic prosthesis along the non-coronary annulus and separation of the aortomitral continuity with abscess cavity formation and fistulization to the right atrium with presence of vegetations.
The abscess cavity was radically debrided and all friable tissue along with the prosthetic valve were removed. Pericardial patch was used for reconstruction of the large AMC defect. Posteriorly, the patch extended from the aortic wall adjacent to the left coronary ostium to the undersurface of the destructed aortic annulus. Inferiorly, it was sutured to the base of the anterior mitral valve leaflet and continued to the right cusp up to the point of the right coronary ostium. Superiorly, it was sutured to the aortic wall (Fig. 2a, b).
As there was barely any healthy tissue to suture a conventional prosthesis, we used a Perceval S® (LivaNova, Saluggia, Italy) size L sutureless valve (Fig. 2c) with our efforts focusing on seating the collar of the valve’s inflow above the annulus.
Subsequently, the right atrium was opened and the vegetations were removed. A small patch was also used on the atrial side to close the fistula and eliminate any communication with the left side and circulation in general.
The patient came off cardiopulmonary bypass easily and was transferred to the intensive care unit with minimum inotropic support. She had an otherwise uneventful postoperative course. Cultures of the excised prosthetic tissue came back negative.
On serial follow-ups, there was no recurrence of endocarditis and the abscess cavity has been resorbed. On a 2-year follow-up, echo showed mild-to-moderate stenosis of the prosthetic valve, trivial mitral regurgitation and preserved EF (Fig. 1c). No perivalvular leak was identified, while the mean and peak gradients were 16 mmHg and 28 mmHg, respectively. The effective orifice area (EOA) was 1.09, AV max was 2.62 m/s, the DVI 0.37, and the acceleration time was 85 ms. Moreover, LV ACC TIME/LV EJECTION TIME was 0.26.