Use of a Valved-Conduit for Exclusion of the Infected Portion in the Prosthetic Pulmonary Valve Endocarditis
A 51-year-old male patient with diabetes was admitted to the division of pulmonology with the chief complaints of fever and hemoptysis. A chest computed tomography scan was performed for the evaluation of persistent fever and recurrent pleural effusion, and it showed pulmonary embolism at bilateral multiple segmental arteries and segmental infarction of the involved lung segments. Based on the results, echocardiography was additionally performed and revealed isolated pulmonary valve infective endocarditis with severe pulmonary regurgitation.\nAfter the diagnosis was made, the patient was treated with antibiotics, followed by echocardiography. The echocardiography showed progression of pulmonary valve thickening and right heart failure. We performed pulmonary valve replacement with a #24 Sorin tissue valve. The postoperative course was uneventful and the patient was followed up at the outpatient clinic regularly with anticoagulation.\nAfter 6 months, he was brought to the emergency unit presenting with a high fever (>39℃) and general weakness that had lasted for 3 days. He was treated with antibiotics including vancomycin, imipenem, and rifampin. Methicillin-sensitive Staphylococcus aureus (S. aureus) was isolated from his blood culture, and the echocardiography showed a hypoechoic movable mass on the prosthetic pulmonary valve () and the pressure gradient of the prosthetic pulmonary valve was 16.2 mmHg (maximum pressure gradient)/9.4 mmHg (mean pressure gradient). Follow-up echocardiography showed a worsened pressure gradient of the prosthetic pulmonary valve. We did a redo-pulmonary valve replacement under the impression of prosthetic valve infective endocarditis.\nThe prosthetic pulmonary valve leaflet was thickened with infected tissue (). After removal of the infected prosthetic valve, a secure portion for the new prosthetic pulmonary valve replacement was hard to find because of the risk of pulmonary vessel wall injury. Moreover, complete debridement of the remaining infected tissue seemed impossible. Thus a valved graft was made by placing a 21 mm tissue valve in the middle of a 22 mm Vascutek artificial graft (). After completely obliterating the proximal portion of the pulmonary arterial lumen with simple suturing for isolation of probable remnant infected debris, the valved graft was used to perform the redo-pulmonary valve replacement similar to the Rastelli operation with right ventricular outflow tract reconstruction ().\nImmediate postoperative echocardiography showed intact prosthetic pulmonary valvular function with a peak pulmonary valve pressure gradient of 34 mmHg and a mean pulmonary valve pressure gradient of 16 mmHg. Follow-up echocardiography was performed on postoperative day #19, and the peak pulmonary valve pressure gradient was 20.71 mmHg, while the mean pulmonary valve pressure gradient was 11.14 mmHg. No more microorganisms were isolated from his blood culture. The patient is currently being treated with anticoagulant (coumadin), presenting no respiratory or cardiovascular symptoms during follow-up in outpatient clinic for 2 years after surgery. The last echocardiography was performed at 15 months after surgery; it showed intact prosthetic valve function with a peak pulmonary valve pressure gradient of 19 mmHg and a mean pulmonary valve pressure gradient of 10 mmHg.