Urgent homograft aortic root replacement for aortic root abscess in infants and children

Abstract

Objective To assess the results of early homograft aortic root replacement in infants and children with an aortic root abscess.

Design Descriptive study of all patients with an aortic root abscess during 1987–97, identified by retrospective review of the echocardiographic and surgical registries.

Setting A tertiary referral centre.

Patients Five patients (age 0.6 to 13 years; two female) were identified with an aortic root abscess. Four had no known pre-existing congenital heart abnormality. Three had a misleading presentation and were referred to our hospital with non-cardiac diagnoses (fulminant hepatic failure; adult respiratory distress syndrome; cerebrovascular accident). The other two presented with septicaemia and a murmur, respectively. Blood cultures identified Staphylococcus aureus(n = 3) and Streptococcus pneumoniae(n = 2). Aortic root abscess was diagnosed by transthoracic echocardiography.

Interventions Homograft aortic root replacement with coronary reimplantation was performed urgently (median one day after diagnosis).

Results Four patients survived. The youngest died following multiorgan failure, multiple aortic fistulae, three valve involvement, and extensive tissue destruction preventing mitral valve replacement (S pneumoniae). Two of the four survivors have required further surgery: mitral valve replacement (0.3 years later), and pulmonary autograft replacement of the homograft (8.3 years later). All survivors remain in sinus rhythm and New York Heart Association functional class I.

Conclusions Infective endocarditis should be considered in any child with severe septicaemia or embolic phenomena. Echocardiographic diagnosis of an aortic root abscess indicates uncontrolled infection and impending haemodynamic collapse. Homograft aortic root replacement can be performed successfully in critically ill children with active infection.