Niwaya K, Kitamura S, Kawata T, Kawachi K, Hosoda Y, Tanaka J, Yamamoto S
Department of Surgery III, Nara Medial College, Kashihara, Japan.
Kyobu Geka. 1996 Jul;49(8 Suppl):688-92.
A 28-year-old male received a redo aortic valve replacement (AVR) with a 19 mm St. Jude Medical mechanical valve 3 months after the initial AVR because of recurrent valve detachment. We re-operated on this patient by aortic root replacement using a fresh aortic homograft. The donor of the homograft was a 59-year-old female who died of a traffic accident. The aortic root and valve was harvested aseptically and stored in a nutrient medium including antibiotics at 4 degrees C for 4 days. At the 3rd operation, aortico-ventricular discontinuity and an annular-abcess-like cavity were found. After debridement, the cavity was closed with a homograft aortic wall and then aortic root replacement was performed using a fresh aortic homograft. At first, prosthetic valve detachment seemed to be caused by infective endocarditis on the basis of his clinical history. However, causative organisms had never been recovered from the blood or the specimens obtained at the time of operation and reoperation. Post-operative HLA examination revealed No. 51 on HLA-B locus and thus we suspected that valve detachment might have been due to inflammation of the aortic wall caused by a subtype of Behçet disease. The early post-operative course was uneventful with a low dose of predonine. Post-operative aortography showed no aortic regurgitation and normal coronary anastomosis. Unfortunately however, he died suddenly 8 months after the operation. Autopsy demonstrated the presence of aortic wall necrosis with massive infiltration of macrophages and leucocytes resulting in dehiscence of the coronary anastomotic site. The cause of homograft detachment could not be determined for sure but might be recurrent infective endocarditis, although causative organisms were never identified, or infective endocarditis in combination with Behçet vasculopathy.
一名28岁男性在首次主动脉瓣置换术（AVR）3个月后，因人工瓣膜反复脱位，接受了再次主动脉瓣置换术，使用的是19毫米圣犹达医疗机械瓣膜。我们对该患者再次进行手术，采用新鲜主动脉同种异体移植物进行主动脉根部置换。同种异体移植物的供体是一名59岁女性，死于交通事故。主动脉根部和瓣膜被无菌采集，并保存在含有抗生素的营养培养基中，于4℃保存4天。在第三次手术中，发现了主动脉-心室连续性中断和一个类似环形脓肿的腔隙。清创后，用同种异体主动脉壁封闭该腔隙，然后使用新鲜主动脉同种异体移植物进行主动脉根部置换。起初，根据患者的临床病史，人工瓣膜脱位似乎是由感染性心内膜炎引起的。然而，在血液或手术及再次手术时获取的标本中从未发现致病微生物。术后HLA检查显示HLA-B位点为51号，因此我们怀疑瓣膜脱位可能是由白塞病的一种亚型引起的主动脉壁炎症所致。术后早期过程平稳，使用低剂量泼尼松。术后主动脉造影显示无主动脉瓣反流，冠状动脉吻合正常。然而，不幸的是，他在术后8个月突然死亡。尸检显示存在主动脉壁坏死，伴有巨噬细胞和白细胞大量浸润，导致冠状动脉吻合部位裂开。同种异体移植物脱位的原因无法确切确定，但可能是反复感染性心内膜炎，尽管从未鉴定出致病微生物，也可能是感染性心内膜炎合并白塞病血管病变。
