Left Ventricular Outflow Tract Reconstruction for Annular Erosion Using a Polyester Graft

Modified Danielson Technique for Prosthetic Aortic Valve Endocarditis and Aortoventricular Discontinuity

Endocarditis is a devastating complication of prosthetic aortic valve replacement. The infective process can destroy aortic annulus tissue, making conventional surgical valve replacement difficult or impossible and causing aortoventricular discontinuity. Several treatment techniques have been proposed. One of these, the Danielson technique, involves translocating the aortic valve to the native ascending aorta, débriding the abscess cavity, closing the coronary ostia, and bypassing the coronary arteries with a Y anastomosis between 2 vein grafts. We describe our use of a modified Danielson technique in a 68-year-old man with advanced prosthetic valve endocarditis that was associated with aortic annulus destruction and aortoventricular discontinuity. This modified technique enables safer, more secure anchoring of a replacement valve, reduces the risks and concerns associated with bypass grafts, and successfully treats aortoventricular discontinuity.

Outcomes After Left Ventricular Outflow Tract Reconstruction With a Tube Graft for Annular Erosion

BACKGROUND

Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement. This study examined the outcomes of a technique for left ventricular outflow tract reconstruction using a polyester tube graft, followed by translocation of the aortic valve and coronary arteries.

METHODS

A total of 23 patients with extensive annular erosion resulting from endocarditis or previous aortic valve replacement with or without pseudoaneurysm formation, or occurring after excision of the native valve, underwent suture of a polyester tube graft in the left ventricular outflow tract below the annulus, replacement of the aortic valve and proximal ascending aorta with a composite graft, and reimplantation of the coronary arteries with the use of interposition polyester grafts. The mean age of the patients was 50 years, and 57% were men.

RESULTS

There were no hospital deaths. The mean duration of follow-up was 6.5 years and extended to 16 years. Actuarial survival at 1, 5, and 10 years was 86.7%, 82.2%, and 62.6%, respectively. Two patients required reoperation for a graft-graft pseudoaneurysm and for degeneration of a porcine bioprosthesis. Echocardiograms obtained at a mean of 75 months postoperatively in 15 of the 23 patients demonstrated normal left ventricular outflow tract dimensions and velocities and a mean effective valve orifice area of 1.07 cm²/m². All coronary artery grafts were patent on angiography a mean of 40 months postoperatively in 13 patients.

CONCLUSIONS

Extended experience with this technique confirms its safety and effectiveness for patients with extensive destruction of the aortic annulus. It represents a suitable alternative to other currently used techniques.

Surgical management of severe damage of the aortic annulus

Aortic annular erosion and abscess are serious complications of prosthetic aortic valve endocarditis and can be treated with aortic valve translocation and left ventricle outflow tract reconstruction. These two surgical techniques seem to have similar early postoperative outcomes, and their use can be considered an option after the failure of conventional surgical methods.

A Technique for Avoiding Patient-Prosthesis Mismatch in the Small Aortic Root

In the small aortic root, extremely weakened tissue and extensive calcification predispose toward the implantation of small prostheses, anastomotic bleeding, and paravalvular leaks. We describe a procedure in which a "homemade" composite mechanical prosthesis-conduit is implanted in a supra-annular position in two patients with a small aortic root. This technique facilitates the placement of a larger prosthesis, thus avoiding patient-prosthesis mismatch. doi: 10.1111/jocs.12741 (J Card Surg 2016;31:309-310).

Circumferential disruption of the ventriculo-aortic junction due to infective endocarditis: surgical repair with custom-made, accurately sized, pericardial tube

Repair of circumferential ventriculo-aortic annular disruption following infective endocarditis is technically challenging. We present an approach for systematic repair and describe a technique for preparation of an accurately sized pericardial tube graft.

Left ventricular outflow tract reconstruction and translocation of the aortic valve for annular erosion: early and midterm outcomes

OBJECTIVE

Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement without endocarditis, and its surgical management is challenging. We present the early and midterm results of a technique for left ventricular outflow tract and aortic root reconstruction with a polyester tube graft and translocation of the aortic valve and coronary arteries.

METHODS

A polyester tube graft is placed into the left ventricle and sutured to the left ventricular outflow tract below the area of erosion. The graft is then everted and sutured to a composite graft. Interposition polyester grafts from the coronary arteries are attached to the composite graft above the valve. This technique has been used in 12 cases. All but 1 patient had previously undergone aortic root or aortic valve replacement, and 4 had endocarditis of prosthetic (n = 2) or aortic allograft (n = 2) valves.

RESULTS

There were no in-hospital deaths. There was 1 early death from pulmonary embolism at 1 postoperative month and 2 late deaths at 15 and 64 postoperative months, both resulting from heart failure. The remaining 9 patients are alive at 3 to 132 postoperative months. Actuarial 5-year survival is 75%.

CONCLUSIONS

Left ventricular outflow tract reconstruction with translocation of the aortic valve and coronary arteries for annular erosion is a useful technique that safely excludes the area of annular erosion and eliminates left ventricular outflow tract obstruction. The procedure can be safely performed with satisfactory early outcomes and 5-year survival.