'Collateral Damage:' Radical Aortic Root Reconstruction for TAVR Endocarditis
Michael A. Catalano1, Jonathan M. Hemli, MD2, Jui-Chuan Tseng, PA-C2, Chad A. Kliger, MD2, Craig Basman, MD2, Luigi Pirelli, MD2, Nirav C. Patel, MD2, S Jacob Scheinerman, MD2, Derek R. Brinster, MD2.
1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA, 2Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA.
OBJECTIVE: Management of an infected transcatheter aortic valve (TAVR) can be challenging, not only from a technical point of view, but also since the patient may have originally undergone the procedure because they were deemed high-risk for traditional surgical valve replacement even in the elective setting. We demonstrate our technique for dealing with an infected TAVR, with particular focus on the extensive reconstruction required of the aortic root and left ventricular outflow tract (LVOT).
METHODS: A 71 year-old male who had a balloon-expandable TAVR and subsequent permanent pacemaker implanted 15-months prior now presented with a septic illness and altered mental status. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Echocardiography demonstrated multiple large vegetations on the aortic valve. The patient had radiologic evidence of numerous septic emboli to the brain, without aneurysm formation or hemorrhage. Our technique for addressing this pathology is demonstrated, incorporating total aortic root reconstruction.
RESULTS: As illustrated in the video presentation, aggressive debridement was required to remove the infected TAVR. Importantly, given the anticipated degree of torqueing inherent in explanting the valve, the coronary buttons were mobilized first, to prevent any inadvertent risk to them during subsequent root manipulation. Complete debridement not only necessitated aortic root replacement with a bioprosthetic valve-graft conduit, but also reconstruction of the aorto-mitral curtain utilizing a patch of xenograft pericardium.
CONCLUSIONS: Aggressive debridement remains the mainstay of therapy for TAVR endocarditis, not infrequently necessitating concomitant replacement of the entire aortic root and patch reconstruction of the LVOT.
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