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Interact CardioVasc Thorac Surg 2009;9:757-758. doi:10.1510/icvts.2009.210617 © 2009 European Association of Cardio-Thoracic Surgery
Multiple sternotomies for repeated aortic root replacement – optimising the surgical approachOxford Radcliffe Hospitals NHS Trust, Oxford, UK Received 28 April 2009; received in revised form 30 June 2009; accepted 7 July 2009
*Corresponding author. Department of General Surgery, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK. Tel.: +44 118 322 5111; fax: +44 118 322 8134.
A 44-year-old patient with fungal endocarditis required a total of five sternotomies over ten years. We present the course of his treatment, details of the surgical techniques employed as well as other interesting points encountered in the management of this patient.
Key Words: Aortic root; Cardiopulmonary bypass; Endocarditis; Infection
A 44-year-old gentleman underwent aortic valve replacement with a mechanical prosthesis for fungal endocarditis (candida albicans) secondary to a pancreatic pseudocyst. Surgery was followed by a course of amphotericin and fluconazole. Six months later, he presented with further signs and symptoms of endocarditis with echocardiography demonstrating a peri-prosthetic leak causing moderate aortic reflux with vegetations and an aortic root abscess. Aortic root replacement with a homograft was performed successfully but during the early postoperative course, he developed severe anginal chest pain with S-T segment depression inferiorly. Cardiac catheterisation seemed to suggest a kink at the anastomosis of his right coronary artery bypass to the homograft. Coronary bypass graft to the distal right coronary artery was performed but his symptoms remained. This subsequently disappeared with discontinuation of amphotericin and he was discharged on long-term fluconazole. Six and a half years later, he presented with angina secondary to tight aortic stenosis. The homograft valve had become heavily calcified over a relatively short period but the right coronary artery and the vein graft were noted to be patent. Aortic root replacement was subsequently performed. Cardiopulmonary bypass (CPB) was established with femoro-femoral cannulation; the left ventricle was vented through a limited left antero-lateral thoracotomy (Fig. 1). This allowed us to establish CPB and cool the patient with the heart defunctioned. Any distension of the heart when it fibrillated when the temperature dropped was prevented by the apical venting.
The aortic homograft was found to be severely calcified and the aortic root was mobilised with difficulty. Both aortic buttons were successfully dissected off and the proximal anastamosis of the saphenous vein graft to the right coronary artery was preserved. The aortic root was reconstructed using a 23-mm Edwards MIRATM mechanical prosthesis sewn into a 30-mm Hemashield Dacron graft. After completion of the graft and coronary anastamoses, the vein graft was anastamosed to the Hemashield tube. Following rewarming and deairing, the heart took over the circulation in a paced rhythm. Histopathology showed no evidence of active inflammation and the extensive calcification was interpreted as a florid degenerative phenomenon. Two years later, a transoesophageal echocardiogram (TOE) showed evidence of infective endocarditis on the mechanical MIRA heart valve with moderate aortic regurgitation; the right ventricular pacing lead also appeared to have a vegetation. Blood cultures grew propionibacterium spp and medical therapy was continued for a month until a repeat TOE showed a paravalvular leak and mild mitral regurgitation. The aortic valve and root were once again replaced as previously using the identical surgical approach. The procedure was covered intra-operatively with vancomycin and a right redo femoro-femoral cannulation for CPB was successfully established. The redo left anterior thoracotomy and left ventricular vent site were dissected out, a redo median sternotomy performed, and the Dacron graft of the previous aortic root replacement was dissected out with very dense adhesions encountered along the way. A new 23-mm MIRA valve sewn into a 30-mm Dacron graft was implanted using semi-continuous polypropylene sutures and the left- and right-coronary buttons were reimplanted onto the Dacron graft with good flow. The right atrium was opened on reduced pump flows to excise the permanent pacemaker leads with vegetations on them. The patient had an uneventful postoperative recovery. He was also most recently seen in early 2009 and is now in full-time employment.
Fungal endocarditis is a devastating diagnosis which requires a combination of both medical and surgical therapy. The current optimum strategy entails lifelong antifungal azole medication along with aggressive surgical debridement and replacement of damaged heart tissue [1]. This unusual presentation of fungal endocarditis raises several interesting points. 2.1. The surgical approach to multiple complex operations on the same patient Surgery for repeated operations on the same patient requires careful planning not only due to previous procedures affecting access but as well as the need for future revisions. Femoro-femoral cardiopulmonary bypass (FFCPB) with systemic cooling prior to resternotomy has previously been described by one of the authors [2]. FFCPB reduces the risk of damage to the great vessels and the heart (especially the right ventricle and previous grafts) as it allows early cardiac decompression and decreases the risk of injury during re-entry into the mediastinum as the heart falls away from the sternum. It also allows easy access to both the venous and arterial systems as opposed to subclavian artery cannulation. For these reasons, FFCPB facilitates optimal control of the operative field and allows earlier myocardial protection in unstable patients [2, 3].2.2. The survival of vein grafts to minimally stenosed coronary arteries The patient's native right coronary artery and venous bypass graft were both found to be patent during his third surgical episode. This challenges the accepted view that competitive flow negatively impacts the patency rates of bypass grafts – where it has previously been described that venous rather than arterial grafts occlude with decreasing severity of the bypassed lesion [4].2.3. Amphotericin as a cause of angina-like symptoms The resolution of the patient's angina upon cessation of amphotericin is unusual – the British National Formulary describes cardiac arrhythmias as a side effect but not ischaemic changes nor chest pain [5]. However, Roden et al. [6] describe an incidence of 20% of patients who experienced chest pain as an acute infusion related reaction associated with liposomal amphotericin B. Resolution of symptoms similarly stopped on cessation of the drug or switching to a non-liposomal formulation.In summary, we present an unusual case of fungal endocarditis which has necessitated complex repeat cardiac surgery resulting in a total of five sternotomies in under ten years. This case illustrates the difficulty in eradicating fungal endocarditis and also highlights notable points regarding its surgical and pharmacological treatment.
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Abstract
1. Introduction