MP63. Surgical Techniques for Four Valve Endocarditis Involving the Aorto-Mitral Fibrous Body: Hemi-Commando Procedure and Pulmonary Valve Homograft
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Jorge Balzan, MD Dr. Jorge Balzan was born in Caracas, Venezuela and is a graduate of Central University of Venezuela. He obtained his medical degree at Zulia University in Venezuela. His residency was at University Hospital of Caracas at Central University of Venezuela where he completed his training in General Surgery and Cardiovascular Surgery. Actually doing a Cardiothoracic Surgery fellowship at Cleveland Clinic, Ohio. Dr. Balzan has ten years’ experience in cardiac surgery, with special interest in robotics and minimally invasive mitral surgery. He is a member of Society of Thoracic Surgery, Venezuelan Society of Surgery. and Panamerican Trauma Society. Before to came to United States in 2016 he was Chief of Cardiovascular Surgery at Santiago de Leon Clinic, co-founder of two cardiovascular surgery programs, Ad-Honorem Cardiovascular Surgeon at Children Cardiology Hospital "Dr. Gilberto Rodriguez Ochoa" and Staff in Trauma and Cardiovascular Surgery at Domingo Luciani Hospital in Caracas, Venezuela. In addition to his surgical practice, he has a full medical license to work in Venezuela as a Cardiovascular an General Surgeon, certified by Ministry of Health of Venezuela and Medical College of Miranda. Dr. Balzan worked at Cleveland Clinc Florida, Department of Surgical Services, Heart Vascular & Thoracic Institute from 2018 to 2022 as IMG assisting surgeries and as well as involved in research and innovations projects. Actually resides in Beachwood, OH with his lovely wife, and two children.
Description
Objective
The endocarditis of 4 valves which involve the aorto-mitral fibrous body, is a condition that expresses severity of disease and for which surgical treatment implies a challenge and poor overall survival.(1) We report the first case successfully treated surgically by developing an hemmicomando procedure and pulmonary valve homograft.
Methods
A 32-year-old female with who was transferred. Currently being treated for infective endocarditis with Vancomycin and Gentamycin. Transthoracic echocardiography showed multiple large AV vegetations (5-25 mm), and mild AS. Blood cultures revealed Streptococcus Species. We performed open heart surgery (Figure 1), Aortic Valve Replacement # 26 Aortic Valve Homograft Hemi-Commando Procedure due to aortic valve endocarditis and aortic root abscess with invasion of the anterior leaflet of the mitral valve, Mitral Valve Repair #30 Annuloplasty Genesee Band, Membranous VSD Repair with Autologous Pericardial Patch, Pulmonary Valve Replacement with #26 Pulmonary Valve Homograft, Tricuspid Valve Repair #28 Annuloplasty MC3 Ring.
Results
As a result of the acute infection, the patient was in her immediate postoperative period with acute respiratory failure hypoxia requiring mechanical ventilation, acute renal failure with electrolyte imbalance. Helicobacter .pylori infection with melena episodes and congestive hepatopathy. Acute on chronic anemia, thrombocytopenia likely secondary to endocarditis and Septic shock. On day 20, a Tracheostomy was performed due to acute post-operative respiratory insufficiency. Postoperatively echocardiogram revealed LVEF 52+-5%, right ventricular systolic function is midly decreased, trace mitral valve regurgitation (Mean gradient 4mmHg), tricuspid valve annuloplasty ring (Mean gradient 2mmHg), homograft aortic valve (trace -+1, peak gradient 5mmHg, mean gradient 3mmHg), pulmonary homograft (peak gradient 16mmHg).
One month after the surgery, the patient is hemodynamically stable with a good recovery with intensive care unit stay, on rehabilitation and without signs of endocarditis or valve insufficiency and still on antibiotics Ertapenem for ESBL Klebsiella pneumoniae and Ceftriaxone for Strep mitis bacteriemia.
Conclusions
Physicians should be aware of this diagnosis which portends an exceedingly complex surgical technique.