Urgent homograft aortic root replacement for aortic root abscess in infants and children

Surgery for paravalvular abscess in children

Objective

To investigate the outcomes of surgery in children with paravalvular abscess at our institution.

Methods

A retrospective review of all patients who underwent surgery for paravalvular abscess was performed.

Results

Between 1989 and 2020, 30 patients underwent surgery for paravalvular abscess, of whom 5 (16.7%) had an intracardiac fistula and 6 (20.0%) had a pseudoaneurysm. Aortic annulus abscesses were most common, occurring in 23 patients (76.7%). Aortic root replacement was performed in 17 patients (56.7%), root reconstruction was performed in 4 (13.3%), and reconstruction of the central fibrous body was required in 5 (16.7%). Postoperatively, 7 patients (23.3%) required extracorporeal membrane oxygenation (ECMO) support, and 1 patient (3.3%) required permanent pacemaker insertion. There were 6 early deaths, 5 of whom were on ECMO, and no late deaths, with a 15-year survival of 79.7% (95% confidence interval [CI], 60.2%-90.3%). Deaths were from sudden cardiac arrest resulting in brain death in 3 patients, inability to wean from ECMO due to severe cardiac dysfunction in 2 patients, and cerebral mycotic aneurysm and hemorrhage in 1 patient. Freedom from reoperation was 40.0% (95% CI, 17.0%-62.3%) at 15 years Reoperation due to recurrence was rare, occurring in only 2 patients (6.7%). Streptococcus pneumoniae (hazard ratio [HR], 9.2; 95% CI, 1.6-51.7) and preoperative shock (HR, 6.4; 95% CI, 1.3-32.0) were associated with mortality. Central fibrous body reconstruction was associated with reoperation (HR, 4.4; 95% CI, 1.2-16.1).

Conclusions

Although paravalvular abscess in children is associated with high early mortality, hospital survivors have good long-term survival. Reoperation is frequent, but is rarely due to recurrence of endocarditis.

Kingella kingae endocardial abscess and cerebral infarction in a previously well immunocompetent child

Kingella kingae is an emerging paediatric pathogen that most commonly is associated with relatively benign osteoarticular disease in children. This report concerns a 1-year-old child with Kingella kingae endocarditis and perivalvular abscess complicated by septic cerebral emboli and osteomyelitis leading to long-term neurological sequelae, highlighting the capacity of this organism to cause severe invasive disease in children.

Aortic root abscess with coronary artery involvement: diagnostic and surgical management

We describe two cases of infectious endocarditis in infants complicated by aortic root abscess involving the coronary artery treated by the Ross operation. Multislice computed tomography was important in defining the diagnosis and in planning subsequent surgical management.

Aortic root abscess with aortico-mitral discontinuity after a ross operation in a child: reconstruction with an oversized homograft

A case of early neo-aortic root abscess following a Ross operation in a 3(1/2)-year-old child is described. The infection destroyed neo-aortic wall with two of the semilunar leaflets detached, and the abscess cavity extended across the intervalvular fibrous body into the left atrium and onto the native mitral valve creating partial "aortico-mitral discontinuity." Reconstruction was successful with an oversized cryopreserved homograft.

Pneumococcal endocarditis in infants and children

We report a case of pediatric pneumococcal endocarditis (PPE) and review the English language literature on this disease. Thirty-two cases of PPE were identified since 1900. One-fourth of these were reported since 1990. Clinical features differed from adult cases, with mitral valve involvement being more frequent and Osler's triad rarely present in children. Congenital heart disease was the only identifiable risk factor. Medical therapy alone resulted in a high mortality rate that was improved in the group of patients receiving combined medical and surgical interventions. PPE is a rare infection that has been reported more frequently in the era of increasing antibiotic resistance. Unlike typical "subacute" endocarditis caused by viridans streptococci, PPE is an aggressive disease with a high mortality rate. Early surgical intervention might improve survival.

Aortic root abscess complicated by fistulization and intracerebral hemorrhagic infarction

We report an unusual case of a 12-year-old male with aortic root abscess complicated by fistulization and intracerebral hemorrhagic infarction. Transesophageal echocardiography provided exact information about the location and dimension. Color-flow mapping demonstrated fistulous communication between the abscess and both the aorta and the left ventricle, causing severe diastolic regurgitation through the paravalvular leak. Pulmonary autograft aortic root replacement was performed with good result.

The Ross procedure for endocarditis in a 4-month-old infant

Streptococcal endocarditis in an infant is rare. We report a case of acute aortic valve endocarditis with abscess and aorta-to-right atrial fistula formation. This 4-month-old infant with a structurally normal heart had been previously well. The child was successfully treated with the Ross procedure and remains well 13 months postoperatively.