Asian Cardiovasc Thorac Ann 2007;15:e14-e15
© 2007 Asia Publishing EXchange Ltd
Shelhigh No-React Pulmonic Valve Conduit for Pulmonary Valve Endocarditis
Neil Roberts, MBChB,
Maciej J Matuszewski, MD,
Nick J Morgan-Hughes, MBChB1,
Glen AL Wilkinson, MBChB
Department of Cardiothoracic Surgery
1 Department of Anaesthesia, Northern General Hospital, Sheffield, United Kingdom
For reprint information contact: Neil Roberts MBChB Tel: 44 208 725 3565 Fax: 44 208 725 2049 Email: neil.roberts{at}stgeorges.nhs.uk, Department of Cardiothoracic Surgery, St. George’s Hospital, Blackshaw Road, London SW17 0QT, United Kingdom.
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ABSTRACT
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Pulmonary valve endocarditis is uncommon, so experience of surgical treatment is limited. A case of pulmonary valve endocarditis in a 26-year-old man, with associated extension into the pulmonary valve annulus and vegetations in the main pulmonary artery, is described. This necessitated surgical excision of the main pulmonary artery and pulmonary valve including the root, annulus, and part of the right ventricular outflow tract. The defect was reconstructed with a Shelhigh No-React porcine pulmonic valve conduit.
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INTRODUCTION
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Pulmonary valve endocarditis is relatively uncommon, and with many patients responding to medical therapy, surgical experience in such cases is limited.1 Drug-resistant organisms, ongoing sepsis, distal embolization, and hemodynamic disturbance are the common indications for surgical treatment.
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CASE REPORT
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A 26-year-old car mechanic presented with a 3-week history of hallucinations and feeling generally unwell, with a productive cough and weight loss of 11 kg. He also complained of diarrhea and a sore mouth. Blood analysis showed albumin 17 g·L–1, hemoglobin 8.6 g·dL–1, platelets 60 x 109·L–1, and a white cell count of 20 x 109·L–1. Initial chest radiography showed lobar pneumonia. The patient was suspected of having a lymphoproliferative disorder and was admitted under the hematology team. Investigations revealed endocarditis of the pulmonary valve and a suspicion of vegetation on the tricuspid valve. Blood cultures grew staphylococcus, and serial chest radiographs showed multiple lung abscesses. The patient was a former drug user who admitted using heroin 7 years prior to admission, but denied injecting intravenously. HIV and hepatitis screens were negative but he was found to have poor oral hygiene with multiple mouth abscesses. After 3 weeks of antibiotics, he was still septic with tachycardia, a swinging temperature, and raised C-reactive protein of 160 mg·L–1. Serial echocardiograms showed a normally functioning tricuspid valve with no obvious vegetation but massive vegetations on the pulmonary artery (PA) and pulmonary valve. At surgery, these findings were confirmed by transesophageal echocardiography (Figure 1
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Figure 1. A modified mid-esophageal long-axis transesophageal echo view, with slight clockwise rotation of the probe to focus in on the right ventricular outflow tract; the right ventricle (RV) and pulmonary artery (PA) are labeled; a vegetation can be seen in the main pulmonary artery (arrowed A), and also a large vegetation can be seen on the pulmonary valve (arrowed B).
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Standard cardiopulmonary bypass was established via a median sternotomy, with bicaval and aortic cannulation. Cold crystalloid cardioplegia was used intermittently via the aortic root. Initially, the right atrium was opened and the tricuspid valve was examined. This valve was normal anatomically with no evidence of vegetation, and a good view into the right ventricle showed no vegetations. The PA was opened to reveal almost complete destruction of all leaflets of the pulmonary valve, with vegetations. There were separate vegetations more distally on the posterior aspect of the main PA and at its closest approximation to the aorta. All vegetations were excised, but this left possible infected tissue in the main PA posterior wall and the annulus. Therefore, the main PA was transected just proximal to the bifurcation, and the dissection was carried proximally (avoiding the left coronary and septal arteries) to include the pulmonary annulus and part of the right ventricular outflow tract. The defect was filled with a Shelhigh No-React (Shelhigh, Inc., Millburn, NJ, USA) porcine pulmonic valve conduit, size 23 mm, trimmed proximally and distally to fit, and inserted with 2 anastomoses of continuous 4/0 Prolene. The patient was rewarmed and weaned from cardiopulmonary bypass with norepinephrine support, in sinus rhythm. He was treated with antibiotics for 6 weeks, and at the 5-month follow-up, he was afebrile with a low serum C-reactive protein of 9 mg·L–1 and leading a fully active life. Chest radiograph showed that his lung abscesses had completely resolved, and echocardiography revealed no vegetations or signs of recurrent infection, and a competent pulmonary valve.
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DISCUSSION
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The goal of surgery is primarily eradication of infection by removal of all infected tissue, but secondarily, it must address the hemodynamic status of the patient in both the short and long term. Opinion on optimal surgical treatment is divided. The choices are pulmonary valvectomy without replacement, or primary valve replacement. The advantage of pulmonary valvectomy without replacement is the good chance of total eradication of infection, which seems sustainable in the medium term.2,3 However, these patients may develop right ventricular dilatation and failure or arrhythmias, requiring medication and possible re-operation.2 In our case with vegetations on the main PA and pulmonary valve annulus, simple valvectomy would not have removed all infected tissue, so it was not a viable option.
When valve replacement is considered, the next decision is which prosthesis to use. In less destructive cases of pulmonary endocarditis, biological valves have been used successfully, but this was not possible in our complicated case.4 In complicated endocarditis of the aortic valve and annulus, the first choice has been a homograft due to its low re-infection rate and functional longevity. However, because of logistic problems of accurate preoperative sizing and availability, the Shelhigh No-React stentless valve has been used as a promising alternative.5 Siniawski and colleagues6 reported that Shelhigh conduits were equally resistant to infection as homografts, when implanted for aortic valve endocarditis. Successful homograft replacement has been reported for pulmonary valve endocarditis, but the logistic considerations complicate operative planning.7 The Shelhigh pulmonic valve conduit was developed as an alternative to the homograft for reconstruction of right ventricle-to-pulmonary artery continuity, primarily in the pediatric population, which has been well documented.8 We chose to use the Shelhigh conduit because of its advantageous features: firstly, it is much easier to acquire than a homograft and a variety of sizes are available off-the-shelf; secondly, the No-React treatment renders the Shelhigh conduit resistant to calcification and infection, a crucial factor in a young patient with active endocarditis. Finally, as well as an excellent hemodynamic profile, the Shelhigh material is easy to handle and suture, which was important in our case due to the extensive dissection that had to be undertaken to remove all the infected tissue, and hence the extended suture line involved in the reconstruction. Our other choices of conduit were a homograft, which was not used due to poor availability, or bovine jugular vein conduit. The bovine conduit is treated with a standard glutaraldehyde protocol and does not offer the same resistance to infection as the Shelhigh conduit. This case illustrates the first use of this conduit for pulmonary valve endocarditis in an adult, which allowed complete excision of infected tissues and restoration of hemodynamic function.
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REFERENCES
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- Marianeschi SM, Iacona GM, Seddio F, Abella RF, Condoluci C, Cipriani A, et al. Shelhigh No-React porcine pulmonic valve conduit: a new alternative to the homograft. Ann Thorac Surg 2001;71:619–23.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
