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Extended Aortic Endocarditis to the Tricuspid Valve : A Trans-aortic Approach
Saadallah TAMER, MD, Laurent De Kerchove, MD, PhD, Philippe Noirhomme, MD, Parla Astarci, MD, PhD, Gebrine El Khoury, MD.
Cliniques Universitaires St-Luc, Woluwe-Saint-Lambert, Belgium.

Extended Aortic endocarditis to the Tricuspid Valve:
The Trans-aortic approach
Patient Demographics:
A 25 year old male patient with no significant medical history is admitted for persistent fever for over 2 months, along with severe dyspnoea and no chest pains.
Relevant History:
Echocardiography showed complete destruction of the aortic valve as well as a 20mm flail peri-aortic abscess on the septal side, extending to the right cavities, along with severe aortic insufficiency (AI), regurgitant volume (RV) at 66mL and ERO at 50 mm2. Prolapse of both cusps of the bicuspid aortic valve was also present and several abscesses of the aortic wall are detected. The pre-operative workup is completed with abdominal as well as brain CAT-Scan, which showed no extra-cardiac vegetations.
Pre-Operative Plan:
Given the presence of paravalvular abscess with severe AI, surgery was necessary. The challenge raised however was the possibility of repairing the valve, considering reconstructing the LVOT, and radical resection of the septum on both sides. Homograft and pericardial patch were provided.
Discussion:
Based on the diagnosis, urgent surgery was performed through a median sternotomy and bicaval cardiopulmonary bypass. Upon aortotomy, infectious damage was assessed showing total destruction of the valve and the septal membrane(a). To avoid contamination and debris embolism, an "en bloc" external dissection was performed allowing us a radical excision undertaking all infected tissue, including the membranous septum and disinsertion of the antero-septal commissure of the tricuspid valve(b). The commissure is then repaired with a 4/0 prolene stitch(c), and the left-right septum is closed using pericardial bovine patch(d). The aortic homograft is used to reconstruct the LVOT. Perioperative TEE showed a competent aortic valve with discrete AI. The patient had a normal post-operative course, except for a permanent pacemaker implantation due to AV block, and antibiotics were maintained for a 6-week period before he was discharged. Follow-up at 28 months was satisfactory, where the patient was asymptomatic and TTE showed discrete AI, no TR, and normal LV function.


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