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Excessive Surgical Adhesive Mimicking Aortic Root Abscess: A Case Report

Silverton, Natalie A. MD*; Bull, David A. MD; Morrissey, Candice K. MD, MSPH*

doi: 10.1213/XAA.0000000000000526
Case Reports: Case Report
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Aortic root abscess is a complication of aortic valve endocarditis that is associated with a high morbidity and mortality. The diagnosis usually is made with transesophageal echocardiography, which is highly sensitive and specific for the disease. We present a case of suspected aortic root abscess 1 week after mechanical aortic valve replacement for native valve endocarditis. The diagnosis was made by the use of transesophageal echocardiography but surgical inspection revealed that the paravalvular fluid collection was excessive surgical adhesive. We discuss the clinical significance and differential diagnosis of aortic root abscess in the setting of infective endocarditis.

From the Departments of *Anesthesiology; and Cardiothoracic Surgery, University of Utah, School of Medicine, Salt Lake City, Utah.

Accepted for publication January 24, 2017.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Natalie A. Silverton, MD, Department of Anesthesiology, University of Utah, 30 N 1900 E, Rm 3C-444, School of Medicine, Salt Lake City, UT 84132. Address e-mail to natalie.silverton@hsc.utah.edu.

Aortic root abscess is a highly morbid form of infective endocarditis (IE) that requires early surgical intervention. Abscess formation in aortic-valve IE usually involves the aortomitral intervalvular fibrosa.1 Delays in surgery can result in devastating complications such as pseudoaneurysm, cardiac fistula, or complete heart block. Debridement of the abscess, usually followed by valve replacement and aortic root reconstruction, is the procedure of choice. This procedure, however, is associated with a perioperative mortality of 11% to 38%.2–4

Transesophageal echocardiography (TEE) is recommended in all patients with IE when transthoracic echocardiography is nondiagnostic or when complications of IE such as paravalvular abscess are suspected.5 Echocardiographic findings consistent with aortic root abscess include swelling or thickening of the tissue around the aortic valve annulus, heterogeneous echogenic material adjacent to aortic root or within the aortomitral curtain, and/or color flow Doppler demonstration of intracardiac fistula between the aortic root and surrounding structures such as the left atrium, right atrium, or right ventricle.

Figure 1.

Figure 1.

Written consent was obtained to present this case of a patient admitted with sepsis, cardiogenic shock, and complete heart block 1 week after aortic valve replacement for native-valve endocarditis. TEE images showed a heterogeneous fluid collection adjacent to the aortic root consistent with aortic root abscess (Figure 1). On reoperation, however, it was discovered that this fluid collection was simply excess surgical adhesive surrounding a normally functioning mechanical prosthetic aortic valve.

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CASE REPORT

A 23-year-old man was admitted to our cardiovascular intensive care unit (CVICU) in cardiogenic shock 1 week after mechanical aortic valve replacement for native-valve endocarditis. The patient originally had presented to an outside hospital with a 1-month history of fevers and was found to have streptococcal bacteremia and aortic valve endocarditis. A 23-mm bileaflet mechanical valve was placed in the aortic position, and an “intracardiac” fistula was repaired with a CorMatrix patch (CorMatrix Cardiovascular, Roswell, GA). His postoperative course was complicated by cardiac arrest and the emergency placement of transvenous pacing wires for complete heart block. He was transferred to our institution for persistent hypotension and hemodynamic instability despite a norepinephrine infusion of 0.4 μg/kg/min.

On admission to our CVICU, TEE was performed, which showed severely decreased left ventricle systolic function with an ejection fraction of 11% and multiple segmental wall motion abnormalities (see Supplemental Digital Video 1, http://links.lww.com/AACR/A98). The bileaflet mechanical aortic valve was well seated (see Supplemental Digital Video 2, http://links.lww.com/AACR/A99) with normal washing jets and no evidence of paravalvular leak (see Supplemental Digital Video 3, http://links.lww.com/AACR/A100). There was a collection of heterogenous echogenic material seen adjacent to the left and noncoronary sinuses of the aortic valve concerning for aortic root abscess (Figure 1). There was also a 1 cm × 2-cm mobile echo density on the septal leaflet of the tricuspid valve (TV) and severe tricuspid regurgitation (Figure 2).

Figure 2.

Figure 2.

Left heart catheterization showed normal coronary arteries. An intra-aortic balloon pump was placed for hemodynamic support. After 24 hours, the patient improved enough hemodynamically to be taken to the operating room for debridement of his presumed aortic root abscess, aortic valve and root replacement with homograft, and TV replacement. After the chest was reopened, surgical exploration revealed an excess of BioGlue surgical adhesive (CryoLife, Kennesaw, GA) posterior to the aortic root that was removed easily with suction. Repeat TEE showed no further evidence of the echo dense material and no evidence of aortic root abscess.

Figure 3.

Figure 3.

Figure 3 shows a long-axis view of the aortic valve before and after removal of the excess BioGlue. Inspection of the TV revealed large vegetation on the septal leaflet with almost total destruction of that part of the valve. After TV replacement, an aortotomy was made to inspect the mechanical valve in the aortic position. It was functioning normally, with no evidence of surrounding aortic abscess. An epicardial lead was placed, and the patient was returned to the CVICU for recovery. His postoperative course was again complicated by a brief episode of ventricular fibrillation and arrest that was caused by poor sensing of the ventricular lead and R on T phenomenon. The patient recovered and was weaned off all hemodynamic support and extubated with no further complications.

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DISCUSSION

BioGlue is a surgical adhesive made from bovine serum albumin mixed with glutaraldehyde. It comes in a dual-chamber mixing syringe and is applied to surgical anastomoses to create a mechanical seal. This type of surgical adhesive often is used in cardiac surgery to improve hemostasis along suture lines. In our case, surgical adhesive likely was used to reinforce sutures around the aortic annulus because valve replacement in IE often is complicated by persistent bleeding resulting from the poor quality of the surrounding infected tissue. The application of excessive BioGlue around the aortic root and in the transverse sinus gave the appearance on TEE of a heterogeneous fluid collection suggestive of an aortic root abscess.

The differential diagnosis for abnormal fluid or material adjacent to the aortic root includes sinus of valsalva aneurysm (usually a congenital anomaly), paravalvular hematoma (commonly found immediately postoperatively with aortic valve replacement), abscess, or pseudoaneurysm. In our case, the clinical suspicion for abscess was high, given the recent history of IE, persistent sepsis, the presumably new vegetation on the septal leaflet of the TV (anatomically adjacent to the noncoronary sinus of the aortic valve), and his severe heart block, requiring emergency transvenous pacemaker placement. Usually aortic root abscess is associated with an infection in the prosthetic valves. In our case, the patient’s prosthetic valve was functioning normally and was well seated with no evidence of dehiscence. It was recognized at the time that an intact prosthetic aortic valve made the diagnosis of aortic root abscess less likely. Surgical intervention, however, was indicated regardless secondary to severe symptoms from IE destruction of the TV.5 If this had not been the case, we might have considered delaying the surgery for further imaging. Other imaging modalities such as cardiac computed tomography or magnetic resonance imaging are a reasonable alternative for evaluating suspected paravalvular infections when they are not clearly delineated by TEE.1,5

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CONCLUSIONS

Aortic root abscess is a complication of IE that requires early intervention that itself is associated with a high perioperative mortality. TEE is recommended for the diagnosis of paravalvular abscess and to evaluate the extension of the abscess into the surrounding tissue. Echocardiographers should be aware of alternate causes of abnormal thickening or fluid accumulation in and around the aortic root as these may have a similar appearance to aortic root abscess. Nonetheless, if clinical suspicion for aortic root abscess is high, surgery must be performed because paravalvular abscess cannot be treated adequately with antibiotics alone, and the consequences of untreated disease are devastating.

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DISCLOSURES

Name: Natalie A. Silverton, MD.

Contribution: This author helped participate in the case, and write and edit the manuscript.

Name: David A. Bull, MD.

Contribution: This author helped participate in the case, and edit the manuscript.

Name: Candice K. Morrissey, MD, MSPH.

Contribution: This author helped participate in the case, and write and edit the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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REFERENCES

1. Habib G, Badano L, Tribouilloy C, et alEuropean Association of Echocardiography. Recommendations for the practice of echocardiography in infective endocarditis. Eur J Echocardiogr2010;11:202219.
2. David TE, Regesta T, Gavra G, Armstrong S, Maganti MDSurgical treatment of paravalvular abscess: long-term results. Eur J Cardiothorac Surg2007;31:4348.
3. Kirali K, Sarikaya S, Ozen Y, et al.Surgery for aortic root abscess: a 15-year experience. Tex Heart Inst J2016;43:2028.
4. Cosmi JE, Tunick PA, Kronzon IMortality in patients with paravalvular abscess diagnosed by transesophageal echocardiography. J Am Soc Echocardiogr. 2004;17:766768.
5. Nishimura RA, Otto CM, Bonow RO, et alACC/AHA Task Force Members. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521e643.

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