Graft Insertion Technique Successfully Resolves Severe Prosthetic Valve Endocarditis Case

Surgeons successfully repaired life-threatening prosthetic valve endocarditis and extensive left ventricular–aortic discontinuity using a modified Bentall procedure combined with a graft insertion technique in a high-risk emergency patient, as detailed in a case report published in General Thoracic and Cardiovascular Surgery Cases. Infective prosthetic valve endocarditis represents an exceptionally dangerous cardiovascular condition characterized by elevated morbidity and mortality, frequently presenting with destructive periannular abscesses. In severe clinical presentations, persistent bacterial destruction can sever the anatomical connection between the left ventricle and aorta, producing left ventricular–aortic discontinuity. This disruption eliminates the natural fibrous ring necessary to anchor standard valve replacements, requiring complex structural reconstructions. Research cited in the report indicates that periannular infectious extension occurs in 9.8 to 40 percent of aortic endocarditis cohorts, while prosthetic valve infections carry higher baseline incidence than native valve infections. Additionally, perivalvular complications develop in approximately 60 percent of prosthetic valve endocarditis patients, often precipitating rapid clinical deterioration.

The reported case centered on a 59-year-old man who presented to hospital care with fever and escalating manifestations of heart failure. His prior surgical history was notable for an emergency hemiarch replacement and aortic valve replacement performed three years earlier to treat acute Stanford type A aortic dissection. Approximately two weeks before presenting to the hospital, the patient developed a sustained fever and received an initial clinical diagnosis of a urinary tract infection from a local practitioner. However, prescribed therapy failed to resolve the febrile episode, and his physical condition progressively deteriorated with worsening respiratory and circulatory distress. The patient was transported to his previous attending physician due to intensifying heart failure symptoms before being urgently transferred to the tertiary surgical center under strong suspicion of infective endocarditis.

On arrival, clinical assessment revealed a blood pressure of 132/70 mmHg, a heart rate of 61 beats per minute, and a body temperature of 35.8 °C. Oxygen saturation was 99 percent with two liters per minute of supplemental oxygen delivered via nasal cannula. Physical examination identified a diastolic murmur peaking at the left border of the third intercostal space. Laboratory testing documented a white blood cell count of 9,320 per microliter with 7,410 neutrophils, a red blood cell count of 3.28 × 10^6 per microliter, hemoglobin of 8.7 grams per deciliter, and hematocrit of 27.8 percent. Platelet counts measured 150 × 10^3 per microliter, serum creatinine was 1.18 milligrams per deciliter, and C-reactive protein reached 5.40 milligrams per deciliter.

Further evaluations revealed marked cardiac stress and coagulopathy, with N-terminal pro-B-type natriuretic peptide reaching 12,237 picograms per milliliter, a prothrombin time–international normalized ratio of 7.56, and an activated partial thromboplastin time of 68.6 seconds. Diagnostic testing identified severe cardiovascular disruption: electrocardiography revealed complete atrioventricular block, while chest radiography showed a cardiothoracic ratio of 68 percent with mild pulmonary congestion. Cardiac computed tomography demonstrated a periannular cavity at the right coronary cusp encroaching upon the ventricular septum toward the right ventricle, alongside a pseudoaneurysm at the proximal anastomosis of the prior hemiarch repair. Transesophageal echocardiography revealed severe regurgitation around the prosthetic valve and abnormal movement of the valve seat, confirming infective prosthetic valve endocarditis, severe aortic regurgitation, periannular abscess, and an anastomotic pseudoaneurysm requiring urgent intervention.

During hospitalization, the patient suffered rapid clinical decline as progressive heart failure overwhelmed compensatory mechanisms. On hospital day four, he experienced sudden hypoxemic respiratory deterioration, with the ratio of arterial oxygen partial pressure to fractional inspired oxygen plunging from approximately 300 to 150. This worsening hypoxemia was accompanied by tachypnea, resting dyspnea, and progressive bilateral pulmonary congestion on radiography, necessitating noninvasive positive-pressure ventilation via bilevel positive airway pressure. Consequently, his condition deteriorated to New York Heart Association Class IV status. Objective risk calculations highlighted extreme surgical danger, yielding a EuroSCORE II of 48.23 percent and a Society of Thoracic Surgeons score of 26.3 percent. Although blood cultures yielded no bacterial growth, antimicrobial therapy with meropenem and vancomycin was initiated promptly, with worsening heart failure necessitating urgent surgery on hospital day five.

During surgery, the ascending aorta graft was clamped and incised, and cardiac arrest was induced by delivering antegrade cardioplegia directly into the coronary ostia. Inspection revealed partial disruption along the proximal anastomotic line of the artificial graft. The prosthetic aortic valve had detached from the annulus between the right coronary cusp and non-coronary cusp, with an adjacent defect penetrating the right ventricle. After removing the prosthesis and resecting infected aortic root tissue while preserving coronary ostia, surgeons identified a periannular abscess extending from the right coronary cusp to the non-coronary cusp. The abscess invaded the ventricular septal muscle and perforated into the right ventricle near the commissure of the septal and anterior tricuspid leaflets. Surgeons meticulously eradicated the abscess using sharp curettes and closed the perforation with direct sutures from the right ventricular side.

Infected tissue was completely cleared from the left ventricular outflow tract, but the anterior part of the aortic annulus was lost, interrupting left ventricular–aortic continuity. To reconstruct the outflow tract, the surgical team deployed the graft insertion technique using a 28-millimeter Gelweave Valsalva graft sized to match the outflow tract. Surgeons cut the graft body to three centimeters, inverted it, and inserted it into the outflow tract. Four horizontal mattress sutures were placed from inside the inserted graft to the epicardial side, anchoring into the interventricular septum below the periannular cavity and the aortomitral fibrous curtain. The edges of the inserted graft and outflow tract were secured with continuous over-and-over sutures. This approach enabled secure double-layer fixation anchored in healthy myocardial tissue, ensuring robust structural stabilization despite widespread destruction of native annular structures.

Following subannular anchoring, the inserted tube graft was pulled out of the left ventricular outflow tract and shortened to leave one centimeter of exposed length. A composite graft comprising a 28-millimeter J-graft Valsalva and a 23-millimeter Inspiris Resilia bioprosthesis was sutured onto the anastomosed graft collar. Coronary arteries were reconstructed using short artificial interposition grafts without twisting, an essential technical precaution to prevent coronary graft thrombosis. After completing outflow tract reconstruction, the surgical team achieved reliable hemostasis without uncontrollable bleeding, bringing the complex emergency operation to a safe conclusion. The authors emphasized that executing double-layer suturing ensured dependable sealing across deeply eroded, fragile myocardial edges.

The case report outlined the comparative surgical reasoning that ruled out alternative operative strategies in this emergency redo scenario. Repeated aortic root surgery carries substantial risk, with literature citing a 13 percent incidence of massive proximal anastomotic bleeding requiring repeat surgery. Xenopericardial patch reconstruction, as described by Uchida and colleagues, requires a relatively intact sinus of Valsalva wall for supra-annular fixation; in this patient, previous hemiarch replacement, a proximal pseudoaneurysm, and infectious extension into the sinus of Valsalva rendered surrounding tissue too fragile. Cryopreserved aortic valve allografts offer recognized infection resistance but face severe availability constraints during emergency surgery in Japan, reflecting broader international patterns where allografts were utilized in only 7.5 percent of root abscess cases. Similarly, the Ross procedure was excluded due to extreme technical complexity and the added operative burden of right ventricular outflow tract reconstruction in an unstable setting.

Institutional logistics and technical trade-offs further guided procedural decisions, including the potential application of antibiotic-soaked grafts. While rifampicin-soaked grafts exhibit high bactericidal activity against Staphylococcus species and enhance resistance against methicillin-resistant Staphylococcus epidermidis when combined with vancomycin, this option was unavailable because institutional ethical approval had not yet been obtained. Additionally, the authors discussed known procedural hazards of graft insertion, notably conduction disturbances and coronary graft thrombosis. Literature indicates permanent pacemaker implantation rates between zero and 18 percent following graft insertion, resulting from deep suture placement into the membranous and muscular ventricular septum. Because the patient had presented with preoperative complete atrioventricular block secondary to deep septal abscess extension, anchoring deeply into the muscular septum and aortomitral fibrous curtain was deemed acceptable and necessary, as these represented the only remaining structural tissues capable of supporting reconstruction.

Postoperative management included prolonged antimicrobial therapy, with intravenous meropenem and vancomycin administered for one month before meropenem was transitioned to ceftriaxone for the remainder of the hospitalization. A permanent cardiac pacemaker was implanted to manage persistent complete atrioventricular block, and the patient was successfully discharged on postoperative day 54. At one-year follow-up, the patient remained free of recurrent infection. Benchmarking these results against broader clinical evidence, Kouchoukos and colleagues reported one-year and five-year survival rates of 86.7 percent and 82.2 percent among 23 patients treated with graft insertion, with reoperations required in only two patients at 51 and 81 months for pseudoaneurysm and graft degeneration. Furthermore, Narita and colleagues demonstrated a 53.1 percent survival rate across one, three, and five years among 14 high-risk redo patients with a mean EuroSCORE II of 28.8 percent, without recurrent endocarditis or adverse aortic events.

The successful surgical outcome demonstrates that the graft insertion technique serves as a viable salvage strategy in exceptionally high-risk redo scenarios where preparation time and reconstructive options are severely restricted. The patient presented with an extraordinary preoperative risk profile, underscored by a EuroSCORE II of 48.23 percent, an STS score of 26.3 percent, and NYHA Class IV functional decompensation, alongside intricate anatomical disruption comprising annular discontinuity and right ventricular perforation after previous arch surgery. By enabling reproducible outflow tract reconstruction without requiring cryopreserved allografts or prolonged preoperative lead time, the procedure provided secure fixation and dependable hemostasis in fragile, infected tissue. Although potential risks of heart block and graft infection remain, the authors noted that this straightforward technique offers an effective option for acute aortic root reconstruction when profound tissue destruction complicates emergency cardiac reoperations.

Subject of Research: Graft insertion technique in modified Bentall surgery for prosthetic valve endocarditis with left ventricular–aortic discontinuity

Article Title: Modified bentall surgery using a graft insertion technique for prosthetic valve endocarditis with left ventricular–aortic discontinuity: a case report

Article References: Sakurahara, D., Nakamura, E., Mori, K., & Furukawa, K. (2026). Modified bentall surgery using a graft insertion technique for prosthetic valve endocarditis with left ventricular–aortic discontinuity: a case report. General Thoracic and Cardiovascular Surgery Cases, 5(1), Article 6. https://doi.org/10.1186/s44215-026-00243-8

Image Credits: AI Generated

DOI: 10.1186/s44215-026-00243-8

Keywords: infective endocarditis, prosthetic valve endocarditis, graft insertion technique, modified bentall procedure, left ventricular-aortic discontinuity, aortic root reconstruction, left ventricular outflow tract, periannular abscess, pseudoaneurysm, complete atrioventricular block, aortic valve replacement, gelweave valsalva graft, inspiris resilia bioprosthesis, hemiarch replacement, euroscore ii, redo aortic surgery, aortomitral fibrous curtain, permanent pacemaker implantation