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症例は47歳,男性.MRSAを起炎菌とする大動脈弁位感染性心内膜炎にて手術を施行した.初回弁輪部膿瘍の直接閉鎖と人工弁置換術を行ったが,術後弁周囲逆流ならびに腔の残存のため再手術を行った.再手術では腔をパッチ閉鎖し弁置換を行ったが,その後も弁周囲逆流は消失せず,腔の残存が確認されたため再々手術を行った.しかし弁周囲逆流と腔は残存し,さらに溶血性貧血が出現した.4度目の手術では,腔をパッチ閉鎖したのち,左冠動脈起始部周辺を剥離し,この部分の弁輪部は大動脈壁外側の左冠動脈下方より,パッチの上縁,人工弁輪と通した.それ以外の弁輪はsupraannularになるよう糸を置き,人工弁の固定を図った.以後弁周囲逆流ならびに腔は消失した.
A 47-year-old man with active aortic valve endocarditis underwent direct closure of a paraannular abscess and valve replacement. Methicillin-resistant Staphylococcus aureus was isolated from his blood culture preoperatively. Because of a postoperative paravalvular leak (PVL) and an echo-free space suggesting a residual cavity, he was reoperated for patch closure of the aneurysm and prosthetic valve replacement. However, the PVL and paraannular cavity were still observed after the 2nd surgery. At the 3rd operation, prosthetic valve detachment along one fourth of its circumference was confirmed, and the cavity was fully opened. A patch was used to cover the pseudoaneurysm and was placed under the orifice of the left coronary artery. This patch repair of the cavity was accomplished, followed by prosthetic valve replacement in situ. Trivial PVL was identified after the operation, and a diagnosis of intravascular mechanical hemolysis was made. Clinical examination revealed partial detachment of the prosthetic valve resulting in a significant PVL and paraannular pseudoaneurysm. Because of unremitting hemolysis and the increased PVL, the patient underwent a 4th repair. Inspection showed that the prosthetic valve was partially detached and the defect was opened at the upper edge. The orifice of the aneurysmal was covered, and valve replacement was performed in the supraannular position using 3 U-stays, which were passed through both the aortic wall and the patch, followed by ascending aortic graft replacement. In the case of aortic valve endocarditis with paraannular involvement, radical debridement and complete reconstruction of the left ventriculoaortic discontinuity without tension are required.
