Bentall-De Bono Reoperation Associated With Pseudoaneurysm and Infectious Endocarditis

We present the case of a 55-year-old patient who underwent the Bentall-De Bono procedure with mechanical prosthesis in 2005 and was admitted to the emergency department in July 2020 with mixed shock. Complementary exams showed an abscess involving the prosthetic tube, two thirds of the aortic valve circumference and the left ventricle, with a neocavity of about 45 mm in diameter from the aortic sinus to the ascending aorta. The patient underwent surgical repair, with a new procedure using the Bentall-De Bono technique, now associated with coronary artery bypass grafting with a great saphenous vein graft between the aorta and the anterior descending artery. Culture of samples collected intraoperatively showed Staphylococcus epidermidis. The patient received antibiotic therapy for 30 days, evolving favorably, and is under regular outpatient follow-up.

Keywords
Reoperation; Operative Surgical Procedures; Endocarditis

Authorship

Janayna Rabelato

Conception and design of the research

acquisition of data

analysis and interpretation of the data

statistical analysis

obtaining financing

writing of the manuscript

critical revision of the manuscript for intellectual content

Instituto Dante Pazzanese de Cardiologia, São Paulo, SP – BrazilInstituto Dante Pazzanese de CardiologiaBrazilSão Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brazil

http://orcid.org/0000-0001-7526-1350

Iuri Betuel Gomes Antonio

Conception and design of the research

acquisition of data

analysis and interpretation of the data

statistical analysis

obtaining financing

writing of the manuscript

critical revision of the manuscript for intellectual content

http://orcid.org/0000-0001-6561-7376

Adnaldo da Silveira Maia Mailing Address: Adnaldo da Silveira Maia Dante Pazzanese Cardiological Institute. Av. Dr. Dante Pazzanese. Postal code: 04012-909. São Paulo, SP – Brazil E-mail: adsm.ccv@gmail.com

writing of the manuscript

critical revision of the manuscript for intellectual content

Universidade de São Paulo, São Paulo, SP – BrazilUniversidade de São PauloBrazilSão Paulo, SP, BrazilUniversidade de São Paulo, São Paulo, SP – Brazil

http://orcid.org/0000-0001-6506-7589

Daniel Chagas Dantas

writing of the manuscript

critical revision of the manuscript for intellectual content

http://orcid.org/0000-0001-6311-7503

Antonio Flávio de Almeida

critical revision of the manuscript for intellectual content

Mario Issa

critical revision of the manuscript for intellectual content

http://orcid.org/0009-0008-1720-6802

Mailing Address: Adnaldo da Silveira Maia Dante Pazzanese Cardiological Institute. Av. Dr. Dante Pazzanese. Postal code: 04012-909. São Paulo, SP – Brazil E-mail: adsm.ccv@gmail.com

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

SCIMAGO INSTITUTIONS RANKINGS

Universidade de São Paulo, São Paulo, SP – BrazilUniversidade de São PauloBrazilSão Paulo, SP, BrazilUniversidade de São Paulo, São Paulo, SP – Brazil

Figures | Tables

Figures (3)
Tables (1)

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Figure 1
The intraoperative view showed the vegetation around the Dacron graft and entering in left coronary artery with the mechanical prosthesis in the center of the figure (A). The composite graft was inserted using multiple sutures reinforced by subannular Teflon (B).

Thumbnail

Figure 2
The final view in the Bentall-De Bono technique combined with coronary artery bypass grafting to the anterior descending artery.

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Figure 3
Electrocardiogram showing regular and sinus rhythm after surgical management of the patient.

Thumbnail

Table 1
Updates to modified duke criteria by the 2023 Duke-ISCVID criteria for infective endocarditis. Adapted from Fowler et al.9

Figure 1 The intraoperative view showed the vegetation around the Dacron graft and entering in left coronary artery with the mechanical prosthesis in the center of the figure (A). The composite graft was inserted using multiple sutures reinforced by subannular Teflon (B).

Figure 2 The final view in the Bentall-De Bono technique combined with coronary artery bypass grafting to the anterior descending artery.

Figure 3 Electrocardiogram showing regular and sinus rhythm after surgical management of the patient.

Table 1 Updates to modified duke criteria by the 2023 Duke-ISCVID criteria for infective endocarditis. Adapted from Fowler et al.9

PATHOLOGIC CRITERIA	Change
Microorganism identification	Microorganisms identified in appropriate sample by PCR, amplicon or metagenomic sequencing, or in situ hybridization
MAJOR CLINICAL CRITERIA	Change
Blood cultures	Removed requirements of timing and separate venipunctures for blood cultures
Definition of typical organisms	Other typical pathogens were added: S. lugdunensis; E. faecalis; all streptococci except S. pneumoniae and S. pyogenes; Granulicatella spp.; Abiotrophia spp.; & Gemella spp. Organisms to be considered ”typical” IE pathogens in the setting of intracardiac prosthetic material: coagulase negative staphylococci, Corynebacterium striatum; C. jeikeium, Serratia marcescens, Pseudomonas aeruginosa, Cutibacterium acnes, non-tuberculous mycobacteria, and Candida spp.
Other microbiological tests	New major criteria for fastidious pathogens: PCR or amplicon/metagenomic sequencing identifies C. burnetii, Bartonella sp., or T. whipplei from blood; or IFA > 1:800 for IgG antibodies identifies B. henselae or B. quintana.
IMAGING
Echocardiography	Similar to earlier versions. Cornerstone of imaging criterion.
Cardiac computed tomography	New major criterion. Findings equivalent to echocardiography.
[18F]FDG PET/CT	New major criterion. Findings for native valve, cardiac device, or prosthetic valve > 3 months after cardiac surgery are equivalent to echocardiography.
Surgical	New major criterion. Intraoperative inspection constitutes Major Criterion in absence of Major Criterion by cardiac imaging or histopathology.
MINOR CLINICAL CRITERIA
Predisposition	Transcatheter valve implant/ repair, endovascular CIED, and prior diagnosis of IE was added.
Fever	Unchanged.
Vascular phenomena	Splenic and cerebral abscess was added.
Immunologic phenomena	Definition for immune complex-mediated glomerulonephritis was added.
Microbiological	PCR or amplicon/metagenomic sequencing evidence of typical pathogen was added.
Imaging	PET/CT evidence < 3 months of cardiac surgery was added
Physical examination	New auscultation of regurgitant murmur when echocardiography is unavailable.

PCR: polymerase chain reaction; FDG: fluorodesoxyglucose; PET/CT: positron emission tomography; CIED: cardiac implantable electronic devices; IFA: indirect immunofluorescence assay; IgG: immunoglobulin G; IE: infective endocarditis.

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Bentall-De Bono Reoperation Associated With Pseudoaneurysm and Infectious Endocarditis

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[1] Mailing Address: Adnaldo da Silveira Maia Dante Pazzanese Cardiological Institute. Av. Dr. Dante Pazzanese. Postal code: 04012-909. São Paulo, SP – Brazil E-mail: adsm.ccv@gmail.com