Near-Complete Obstruction of an Aortic Homograft

Aortic valve replacement in the setting of aortic valve endocarditis frequently is managed with an aortic homograft. However, late operation is not uncommon and may be very difficult because of calcification of the wall of the aortic homograft and the valve leaflets.1–3 We report a patient with a heretofore unreported complication with near-complete obstruction of his aortic homograft.A 38-year-old man was referred to the Bluhm Cardiovascular Institute at Northwestern University for surgical management of suspected aortic prosthesis dysfunction. He had undergone aortic valve replacements at 16 and 24 years of age, and at 25 years of age, he developed prosthetic valve endocarditis, which was treated with cryopreserved homograft aortic valve and root replacement. He required partial sternectomy for sternal osteomyelitis weeks later and an implantable cardioverter-defibrillator for perioperative ventricular arrhythmias. He recovered fully. In 2009, the patient developed weekly episodes of numbness, paresthesia, and weakness lasting from 15 minutes to several hours. In the fall of 2010, progressive fatigue and dyspnea on exertion progressed to near syncope. Echocardiographic (Figure 1) and computed tomography (Figure 2) scans suggested obstruction of the aortic homograft. At Northwestern, echocardiographic imaging from the apical transducer position demonstrated no aortic stenosis or regurgitation with a mean gradient of 6 mm Hg across the valve (Figure 1A). …