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\begin{document}

\title{Use of rapid deployment aortic valve prosthesis and patch reconstruction
in a complex endocarditis.}



\author[1]{Antonio Piperata}%
\author[2]{TOMASO BOTTIO}%
\author[2]{Martina Avesani}%
\author[2]{Giulio Folino}%
\author[1]{Ermanno Bellanti}%
\author[1]{Gino Gerosa}%
\affil[1]{Affiliation not available}%
\affil[2]{Universita degli Studi di Padova Dipartimento di Medicina}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\selectlanguage{english}
\begin{abstract}
We describe the case of a 59-year old female affected by aortic
extensive endocarditis with communication between aortic annulus and
right cavities, treated with double pericardial patch reconstruction and
rapid-deployment aortic valve prosthesis implantation.%
\end{abstract}%



\sloppy


\textbf{Title} : Use of rapid deployment aortic valve prosthesis and
patch reconstruction in a complex endocarditis.

Antonio Piperata\textsuperscript{1*} MD, Tomaso
Bottio\textsuperscript{1*} MD, PhD, Martina Avesani MD, Giulio
Folino\textsuperscript{1} MD, Ermanno Bellanti\textsuperscript{1} MD,
Gino Gerosa\textsuperscript{1}, MD.

\textsuperscript{1}Department of Cardiology, Thoracic, Vascular, and
Public Health Sciences, University of Padua, via N. Giustiniani, 2,
35128 Padova, Italy

*The first two authors equally contributed.

\textbf{Short title:} Rapid deployment in endocarditis

Corresponding Author: Tomaso Bottio,

Via Giustiniani, 2

35100

Padova

Italy

Phone: +39 0498212428

+39 335328307

E-mail:\emph{tomaso.bottio@unipd.it}

\textbf{Word count} : 1141

Total number of figures: 2

\textbf{The authors do not have any conflict of interest to declare.}

ABSTRACT

We describe the case of a 59-year old female affected by aortic
extensive endocarditis with communication between aortic annulus and
right cavities, treated with double pericardial patch reconstruction and
rapid-deployment aortic valve prosthesis implantation.

KEYWORDS: Rapid deployment, Infective Endocarditis, Patch Reconstruction



\textbf{Case Report}

We describe the case of a 59 year old female with a history of insulin
dependent type 2 diabetes and obesity, admitted to our hospital with
severe metabolic acidosis. She appeared neurologically oriented, pyretic
(38\selectlanguage{ngerman}°C), with very low diastolic blood pressure values and significant
contraction of diuresis.

Electrocardiogram showed sinus tachycardia. Lab-work revealed nothing
but leukocytosis with white blood cell count of 16,000/mm3. No other
meaningful data was noted .

Trans-thoracic echocardiogram (TTE) revealed normal left ventricular
dimension and function, with ejection fraction (EF) of 65\% and no
regional wall motion abnormalities. However, very large and mobile
vegetation was seen attached to the atrial side of the septal
tricuspidal leaflet, causing moderate tricuspid valve regurgitation. A
huge aortic vegetation and periannular abscess causing severe aortic
valve regurgitation was also noticed.

Trans-Esophageal Echocardiogram (TEE) revealed a tunnel among the aortic
valve, right atrium, and right ventricle, with left to right shunt, and
also confirmed the presence of voluminous masses attached to the
tricuspid and aortic valves (Fig I A).

During the following two days, despite antibiotic coverage with
intra-venous ampicillin, cefazolin and gentamicin since admission, the
patient rapidly worsened, requiring support of high doses of inotropes
and intubation. Moreover, she developed acute kidney injury and
worsening anemia.

A total body CT scan was performed to exclude possible peripheral
embolization and identify possible sites of infection. The test gave
negative results.

Thus, we decided to perform urgent surgery.

\textbf{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 described\textsuperscript{1}.

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.

\textbf{Discussion}

At present, surgical management of aortic valve endocarditis is based on
the use of conventional stented mechanical,
bioprostheses\textsuperscript{1,3}, or when possible, stentless
bioprostheses\textsuperscript{4}.

In this case, the choice of this prosthesis was related to the poor
quality of the aortic annulus. The reconstruction with the pericardial
patch started deep within the interventricular septum and then covered
and anchored the anterior mitral valve leaflet to the aortic wall. This
was because of a gap generated by the deficiency of the deteriorated
annulus. For this reason, we preferred not to use sutures with pledgets
to pass in the area recently reconstructed with the patch, but instead
we preferred to exclude this area using a rapid deployment
bioprosthesis.

The subvalvular skirt of Intuity stabilized the prosthesis to the aortic
annulus and excluded our reconstructed zone from the left ventricular
outflow, with the aim of reducing the chance of interventricular defect
reopening due to the left ventricle outflow blood jet. Additionally, the
radial force could transmit solidity to the surrounding tissues and
ensure more stability to the reconstructed structures

Finally, soon after the heart was reperfused, and an AV complete block
was evident, we preferred to implant two definitive epicardial leads
(atrial and ventricular) convenient for A-V pacing, avoiding
intravascular leads that have more chances to complicate new cases of
endocarditis in presence of positive blood cultures.

The patient continued the antibiotic therapy for 6 weeks following
surgery. She was screened again after 6 months and she did not show any
recurrences of endocarditis, prosthetic dysfunctions, or intracardiac
shunts.

\textbf{Conclusion}

In conclusion, we described the case of an active infective endocarditis
complicated by an extensive aortic annulus abscess with three cardiac
chamber communication. It was successfully repaired with double
pericardial patch and completed with the implantation of a rapid
deployment prosthesis.



\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del
  Zotti F, \emph{et al.}2015 ESC Guidelines for the management of
  infective endocarditis: The Task Force for the Management of Infective
  Endocarditis of the European Society of Cardiology (ESC). \emph{Eur.
  Heart J.} 2015;36:3075-3128
\item
  Edwards MB, Ratnatunga CP, Dore CJ, Taylor KM. Thirty-day mortality
  and long-term survival following surgery for prosthetic endocarditis:
  a study from the UK heart valve registry.\emph{Eur. J. Cardio-Thoracic
  Surg.1998;} 14:156--164.
\item
  Rizzoli G, Bottio T, De Perini L, Scalia D, Thiene G, Casarotto D.
  Multivariate analysis of survival after malfunctioning biological and
  mechanical prosthesis replacement. \emph{Ann. Thorac. Surg} .
  1998;66:S88-94.
\item
  Repossini A, Bacco LD, Gazdag L, Grubitzsch H, Fischlein T, Stara A,
  \emph{et all} . Is the Freedom SOLO Stentless Bioprosthesis a Useful
  Tool for Patients with Aortic Endocarditis and Aortic Annular
  Destruction?\emph{Thorac Cardiovasc Surg}. 2019; 67:644-651
\end{enumerate}

\textbf{Figure Legends}

\textbf{FIGURE I: Pre-operative presentation}

A: Intraoperative view. The arrow: Through the aortic valve it is
possible to see the septum

B: Abscess and vegetation across interatrial- and interventricular-
septum

1: Abscess and vegetation across interatrial- and interventricular-
septum, 2: Shunt from aorta to right heart cavities

C: Preoperative Trans-Esophageal Echocardiogram. LA: Left Atrium, LV:
Left Ventricle, RV: Right Ventricle, 1: Abscess

\textbf{FIGURE II: Post-operative result}

A: 1: Rapid-Deployment aortic valve prosthesis; 2: Double pericardial
patch reconstruction.

B: Echocardiographic control, LA: left atrium, LV: Left ventricle, RA:
Right atrium, 1: rapid deployment prosthesis, 2: patch reconstruction.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
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