Short of tricuspid valve replacement, many other methods can be used to repair the tricuspid valve. If the tricuspid valve still has cordal attachments, an autologous patch can be used to repair the septal leaflet. If the leaflet damage is too great, advancing tricuspid flaps can be used with tricuspid annuloplasty techniques to primarily repair the septal leaflet. Often, however, the tricuspid valve damage is too extensive to allow for adequate repair techniques, and a tricuspid valve replacement is necessary.
16.1.2 Aortic Valve Repair/Replacement for Bacterial Endocarditis
Aortic valve endocarditis in patients with persistent or residual VSD tends to cause sepsis and hemodynamic instability. Moreover, the threat of cerebral and systemic embolization adds to the patient’s precarious condition. Patients often present with previous cerebral embolization, which challenges the operative decision because the anticoagulation required for the reparative operation could cause an extension of the embolic stroke. Experienced decisions and solutions guide the surgeon in the timing and performance of an operation that is life-saving and preserves patient well-being.
Endocarditis affecting the aortic valve in patients with congenital heart disease represents an anatomic continuum of conditions. Decisions may be guided by echocardiography but more often require immediate judgment based on the operative findings. When the infection is confined to one leaflet, reparative operations have been described that involve biologic patch repair of a hole when the periphery of the leaflet is intact. Further destruction of the valve leaflets require valve replacement, provided that the annulus is preserved and holds sutures for the implant. When the infection is severe, it can extend into the annulus and subannular area to form an abscess. These conditions require careful consideration, as the reparative process may involve neighboring valves and interventricular muscle debridement.
Mitral/aortic annular involvement also requires well-placed biologic patches to obliterate the abscess and repair the anterior leaflet of the mitral valve. The same biologic patch can be applied to the membranous septum, although the exposure requires right atrial entry to complete the repair. The native VSD requires pericardial patch closure using interrupted suture technique.
The best solution for aortic valve replacement in the young adult with congenital heart disease and aortic valve endocarditis not amenable to repair is the Ross operation. The Ross operation has the obvious benefits of an autologous graft, which include excellent hemodynamics, bacterial resistance, and freedom from warfarin anticoagulation. The principles and techniques of this operation do not vary from the usual indications of left ventricular outflow tract obstruction and are described in Chap. 14. Before this operation is contemplated, however, the surgeon must ascertain that there is a well-defined subpulmonic muscular conus that will allow autograft implantation into the left ventricular outflow tract. Patients with doubly committed VSDs or with VSDs that extend to the pulmonary annulus will not have a well-defined subpulmonic muscle ring that is necessary for aortic implantation. These patients are therefore better treated by other methods such as aortic homografts or free-style heterografts.
Alternatively, a simple aortic valve replacement can be performed using a bioprosthetic valve, assuming that the valve annulus is not destroyed and can hold sutures for proper device implantation. In the case of a destroyed annulus, a valved conduit can be constructed using a bioprosthetic valve implanted or sewn into a graft, which can be used to perform a Bentall operation with reimplantation of the coronary arteries as noted above.
Aortic valve endocarditis can also involve the mitral valve and requires concomitant mitral valve repair or replacement. Solutions to this problem include anterior leaflet repair and bioprosthetic mitral valve replacement.