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.