Destructive Endocarditis of Three Chambers of the Heart

A 67-year-old marathon runner and Ironman competitor with a history of aortic valve replacement and ascending aortic aneurysm repair presented to an outside hospital with strep viridans endocarditis, leading to a root abscess and pseudoaneurysm. He experienced cardiac arrest with return of spontaneous circulation (ROSC), developed complete heart block requiring pacing, and acute kidney injury necessitating dialysis. Subsequently, he was transferred to the authors’ institution, where he went into septic shock requiring low dose pressors and showed increasing lactate levels as well as elevated alanine transaminase (ALT) and aspartate aminotransferase (AST). 
 
Given the patient's complex history and critical condition, emergent surgery was deemed necessary despite the risks associated with possible active sepsis or developing cardiogenic shock. The surgical procedure involved a redo sternotomy and extensive debridement of a large abscess affecting the aortic root, left ventricular outflow tract (LVOT), free left ventricular (LV) wall, ventricular septum, tricuspid valve, and a significant portion of the right atrium. 
 
An aortic root homograft was utilized, including reconstruction of the mitral valve with a homograft mitral valve and reconstruction of the ventricular septum using a homograft and pericardial patch. Additionally, the right atrial free wall was reconstructed with closure of the Gerbode defect using a bovine pericardial patch. The tricuspid valve was repaired with a #28 MC3 annuloplasty and anteroseptal commissuroplasty using native pericardium. 

References

1. Maeba S, Kawashima D, Saito M, Okano R, Sunada M, Ito T. Extensive aortic root endocarditis caused ventricular septal rupture. Gen Thorac Cardiovasc Surg. 2022 Apr; 70(4):394-397. doi: 10.1007/s11748-021-01761-8. Epub 2022 Jan 23. PMID: 35066786.
2. Leyh RG, Knobloch K, Hag C, Ruhparwar A, Fischer S, Kofidis T, Haverich A. Replacement of the aortic root for acute prosthetic valve endocarditis: prosthetic composite versus aortic allograft root replacement. J Thorac Cardiovasc Surg. 2004 May; 127(5): 1416-20. doi: 10.1016/j.jtcvs.2003.08.047.PMID:15116001.

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