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Sutureless Prosthetic Aortic Valve Endocarditis: A New Form of an Old Disease

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Sutureless Prosthetic Aortic Valve Endocarditis:
A New Form of an Old Disease
Sreekumar Subramanian, MD; Parag Patel, MD; Joshua Hall PA-C
TriStar Centennial Medical Center (HCA)
Nashville, USA

Patient Demographics and Clinical Course:

•73 year old man undergoes Perceval sutureless aortic valve for classic, high-gradient severe aortic stenosis, and had no evidence of endocarditis .
• Medical history notable for recurrent preoperative bacteremia and  buttock abscess drainage.
•Intraoperative TEE shows well-seated valve without AI. (see Fig. 1)
3 weeks postoperatively, the patient was readmitted with Enterococcal bacteremia and complete heart block
•Echocardiogram showed  no vegetations or evidence of endocarditis, but new trivial  perivalvular AI.
•Pacemaker implanted after blood cultures sterilized.
•Patient was recommended 6 weeks of antibiotic therapy, but was noncompliant.
 
2 months  postoperatively, he was readmitted with heart failure, fever and malaise, and recurrent Enterococcal bacteremia.
•TEE showed  moderate to severe perivalvular aortic insufficiency (see Fig. 2).
•CT scan showed an aortic root abscess. (see Fig. 3)

Key  operative findings:

•Inflow ring was still  adherent to aortic annulus, except in the region of the  commissure between left and non-coronary cusps where there was a space  (causing perivalvular leak) and a focal aortic root abscess.
•Outflow ring was densely adherent to the ascending aorta, but could be separated from the ascending aorta bluntly, and a bovine pericardial patch was used to reinforce  this area.
•Abscess  debrided and bovine pericardial patch was used to reconstruct the aortic annulus. The explanted valve did not display any vegetations or evidence of structural valve deterioration.
•Following sterilization of the annulus, a sutured aortic bioprosthesis was implanted. The patient recovered uneventfully and was discharged to rehabilitation for completion of his antibiotic therapy, and remains clinically well at six weeks.
 

Discussion:

•Bacteremia, late conduction disturbances, new aortic insufficiency/perivalvular leak, and  aortic root abscess are findings of sutureless and sutured prosthetic aortic valve endocarditis.
•Given the absence of sutures, the reported incidence of sutureless aortic valve endocarditis is extremely low.
•Operative findings in sutureless valve endocarditis may be more subtle , and explantation of the outflow ring requires care to avoid aortic intimal injury.
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