Gerbode defect and left ventricular-aortic discontinuity in prosthetic valve endocarditis
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CASE REPORT Artificial Valve
Gerbode defect and left ventricular‑aortic discontinuity in prosthetic valve endocarditis Tetsuro Uchida1 · Azumi Hamasaki1 · Yoshinori Kuroda1 · Atsushi Yamashita1 · Shingo Nakai1 · Kimihiro Kobayashi1 · Mitsuaki Sadahiro1 Received: 15 October 2019 / Accepted: 26 December 2019 © The Japanese Society for Artificial Organs 2020
Abstract Communication between the left ventricle and right atrium is known as the Gerbode defect. The defect is usually congenital but can be acquired secondary to infective endocarditis. Left ventricular-aortic discontinuity is another serious complication of extensive infective endocarditis. Here, we report a rare case of prosthetic valve endocarditis complicated with both acquired Gerbode defect and left ventricular-aortic discontinuity. We successfully performed reconstructive surgery involving patch closure of the Gerbode defect and reconstruction of the circumferential left ventricular outflow tract with a xenopericardial patch, followed by supra-annular aortic valve replacement with the Solo Smart bovine pericardial stentless valve. Keywords Stentless bioprosthesis · Gerbode defect · Prosthetic valve endocarditis · Left ventricular-aortic discontinuity
Introduction
Case report
Left ventricular (LV)–right atrial (RA) communication, commonly known as the Gerbode defect [1], is usually congenital, but acquired cases can occur following infective endocarditis (IE), myocardial infarction, and valvular surgery [2, 3]. Another serious complication of extensive IE is LV-aortic (Ao) discontinuity, which necessitates complex surgery associated with high mortality and morbidity. Here, we report a rare surgical case of prosthetic valve endocarditis (PVE) complicated with both acquired Gerbode defect and LV-Ao discontinuity.
A 70-year-old man who had undergone mechanical aortic valve replacement (AVR) twice presented with high fever, exertional dyspnea, and complete atrioventricular block. He was referred to our institution for further examination. Transthoracic echocardiography demonstrated PVE with vegetation. Prosthetic valve dehiscence and extensive peri-annular abscess formation were also noted. Although tricuspid valve annular vegetation was observed, no tricuspid regurgitation was recognized. Blood culture was positive for Streptococcus agalactiae and, thus, antibiotic therapy was started. On an urgent basis, redo AVR with annular reconstruction and resection of the tricuspid vegetation were planned subsequent to the placement of an intravenous temporal pacemaker lead for complete atrioventricular block. Considering the high risk of pulmonary embolism owing to the tricuspid vegetation, the pacemaker lead was carefully inserted into the right ventricle through the diseased tricuspid valve. Following sternal reentry, a cardiopulmonary bypass was established with ascending aortic and bicaval cannulation. Through the transverse aortotomy, the aortic prosthesis was inspected. Two-thirds of the circumference of the mechanical valve was detached from the annul
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