Treatment For Infected Frozen Elephant Trunk Prosthesis Caused by <i>Propionibacterium acnes</i>: A Surgical Challenge

In this article, we present the case of a 47-year-old man who underwent Bentall-Bono procedure and frozen elephant trunk prosthesis implantation due to severe aortic regurgitation and aortic dilatation with a second-time endovascular stent-graft repair in descending aorta. Over eight years, a subacute graft infection by Propionibacterium acnes was developed, culminating in cardiogenic shock secondary to severe aortic regurgitation due to a complete aortic root dehiscence because of multiple aortic pseudoaneurysms. The patient underwent emergency surgery in which the replacement of the graft by a biological valve tube was performed accompanied by a complete debranching of the three supra-aortic vessels.

Keywords:
Aortic Valve Insufficiency; Aortic Diseases; Propionibacterium acnes; Dilatation; Blood Vessels Prosthesis Implantation; Stents

Authorship

Laura Varela Barca Correspondence Address: Laura Varela Barca, https://orcid.org/0000-0002-4605-8801, Cardiovascular Surgery Department, Instituto de Investigación Sanitaria - Fundación Jiménez Díaz, 2, Reyes Católicos Avenue, Madrid, Spain, Zip Code: 28040, E-mail: lauravarela21089@gmail.com

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

drafting the work or revising it critically for important intellectual content

final approval of the version to be published

Cardiovascular Surgery Department, Instituto de Investigación Sanitaria - Fundación Jiménez Diaz, Madrid, SpainFundación Jiménez DiazSpainMadrid, SpainCardiovascular Surgery Department, Instituto de Investigación Sanitaria - Fundación Jiménez Diaz, Madrid, Spain

https://orcid.org/0000-0002-4605-8801

Laura Esteban-Lucia

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

drafting the work or revising it critically for important intellectual content

final approval of the version to be published

Cardiology Department, Instituto de Investigación Sanitaria - Fundación Jiménez Diaz, Madrid, SpainFundación Jiménez DiazSpainMadrid, SpainCardiology Department, Instituto de Investigación Sanitaria - Fundación Jiménez Diaz, Madrid, Spain

Marta Tomás-Mallebrera

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

drafting the work or revising it critically for important intellectual content

final approval of the version to be published

Radiology Department, Instituto de Investigación Sanitaria - Fundación Jiménez Diaz, Madrid, SpainFundación Jiménez DiazSpainMadrid, SpainRadiology Department, Instituto de Investigación Sanitaria - Fundación Jiménez Diaz, Madrid, Spain

Ana Pello-Lázaro

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

drafting the work or revising it critically for important intellectual content

final approval of the version to be published

Gonzalo Aldámiz-Echevarría

Substantial contributions to the conception or design of the work

or the acquisition

analysis

or interpretation of data for the work

drafting the work or revising it critically for important intellectual content

final approval of the version to be published

Correspondence Address: Laura Varela Barca, https://orcid.org/0000-0002-4605-8801, Cardiovascular Surgery Department, Instituto de Investigación Sanitaria - Fundación Jiménez Díaz, 2, Reyes Católicos Avenue, Madrid, Spain, Zip Code: 28040, E-mail: lauravarela21089@gmail.com

No conflict of interest.

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Figures | Tables

Figures (4)
Tables (1)

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Fig. 1
(A) Volume-rendering computed tomography (CT) angiography presenting the successful aortic root and ascending aorta replacement using the frozen elephant technique and the correction of descending aorta enlargement, by placing a two-piece combination stent. (B-C) Volume-rendering CT angiography images showing periprosthetic pseudoaneurysms (arrows) and a large pseudoaneurysm (*) involving the supra-aortic vessels.

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Fig. 2
Transthoracic echocardiogram showing severe ventricular dilatation (left ventricular end-diastolic diameter of 68 mm) and massive aortic insufficiency because of ring suture dehiscence.

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Fig. 3
Computed tomography scan showing three aortic pseudoaneurysms: a proximal one extended above and below the prosthetic valve with wide communication with the left ventricle, a second pseudoaneurysm adjacent to the ostium of the reimplanted left coronary artery, and a posterior pseudoaneurysm that runs parallel to the aortic graft in the aortic arch without apparent communication with the previous pseudoaneurysms. RCA=right coronary artery.

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Fig. 4
Volume-rendering computed tomography angiography after surgery showing the new composite aortic root graft and the four-branched prosthetic aortic arch graft with reimplantation of supra-aortic vessels (SAV) (square brackets). A third Dacron tube graft (*) is used to connect the left coronary artery (LCA) to the ascending aortic graft.

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Abbreviations, Acronyms & Symbols CT = Computed tomography HP = Hybrid prosthesis LCA = Left coronary artery RCA = Right coronary artery SAV = Supra-aortic vessels TTE = Transthoracic echocardiogram

Fig. 1 (A) Volume-rendering computed tomography (CT) angiography presenting the successful aortic root and ascending aorta replacement using the frozen elephant technique and the correction of descending aorta enlargement, by placing a two-piece combination stent. (B-C) Volume-rendering CT angiography images showing periprosthetic pseudoaneurysms (arrows) and a large pseudoaneurysm (*) involving the supra-aortic vessels.

Fig. 2 Transthoracic echocardiogram showing severe ventricular dilatation (left ventricular end-diastolic diameter of 68 mm) and massive aortic insufficiency because of ring suture dehiscence.

Fig. 3 Computed tomography scan showing three aortic pseudoaneurysms: a proximal one extended above and below the prosthetic valve with wide communication with the left ventricle, a second pseudoaneurysm adjacent to the ostium of the reimplanted left coronary artery, and a posterior pseudoaneurysm that runs parallel to the aortic graft in the aortic arch without apparent communication with the previous pseudoaneurysms. RCA=right coronary artery.

Fig. 4 Volume-rendering computed tomography angiography after surgery showing the new composite aortic root graft and the four-branched prosthetic aortic arch graft with reimplantation of supra-aortic vessels (SAV) (square brackets). A third Dacron tube graft (*) is used to connect the left coronary artery (LCA) to the ascending aortic graft.

Abbreviations, Acronyms & Symbols
CT	= Computed tomography
HP	= Hybrid prosthesis
LCA	= Left coronary artery
RCA	= Right coronary artery
SAV	= Supra-aortic vessels
TTE	= Transthoracic echocardiogram

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Treatment For Infected Frozen Elephant Trunk Prosthesis Caused by <i>Propionibacterium acnes</i>: A Surgical Challenge

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[1] Correspondence Address: Laura Varela Barca, https://orcid.org/0000-0002-4605-8801, Cardiovascular Surgery Department, Instituto de Investigación Sanitaria - Fundación Jiménez Díaz, 2, Reyes Católicos Avenue, Madrid, Spain, Zip Code: 28040, E-mail: lauravarela21089@gmail.com