Technique
During surgery, two vegetations were seen on the septal leaflet of the tricuspid valve and were removed immediately after the heart arrest. In this way, the direct communication among the right atrium, the aorta, and the right ventricle could be clearly seen (Fig I B, C). It was caused by an enormous abscess which had destroyed not only the aortic annulus, but also the junction between the aortic annulus, the inter atrial septum and the interventricular septum ( Fig IC).
The abscess was completely opened, cleaned, and closed with a double patch. From right-atrial approach, the continuity between the interventricular septum and the interatrial septum was restored by using pericardial patch. The septal leaflet of the tricuspid valve was reconstructed with triangular pericardial patch. In a second step, through trans-aortic approach, we restored the continuity between the interventricular septum, the anterior leaflet of the mitral valve and the aortic annulus using a second pericardial patch. Then we reconstructed the aortic annulus with the same patch (Fig II A).
We then decided to implant Edwards Intuity Elite prosthesis for two main reasons. Firstly, to avoid sutures, which could stretch the fragile annular tissue. Secondly, the subannular portion of the prosthesis might protect the repaired septum from the high-velocity jet coming from the left ventricle.
The implantation technique of Edwards Intuity Elite was performed as previously described1.
The total CPB and cross-clamp times were 102 and 163 minutes, respectively.
The microbiological test on the explanted valve showed the presence of staphylococcus aureus.
At the end of the procedure, permanent pacemaker leads were implanted because of atrio-ventricular (AV) block. Post-operative TEE showed perfect competence of the prosthesis and absence of perivalvular leaks and inter-ventricular septal defects (Fig II B)
The ICU- and total hospital stay were 2 and 8 days, respectively.
The six months ecochardiographic and clinical follow-up is uneventful, with normal transvalvular gradients and no appearance of peri-valvular leaks.