Ascending Aorta and Total Aortic Arch Replacement in a Child with Infective Endarteritis

Infective endarteritis, a special type of infective endocarditis caused by aortic stenosis, remains uncommon, although patent ductus arteriosus and aortic coarctation accounting for infective endarteritis have been reported in a few cases (1). Here, we report a 12-year-old boy with ascending aortic stenosis, who developed infective endarteritis and aneurysm, underwent a successful ascending aorta and total aortic arch replacement, which is extensively employed to treat aortic diseases. A 12-year-old boy was admitted to our hospital on August 4, 2017 because of complaints of on and off fever for 1 month and intermittent claudication for 3 days. During admission, his body temperature was 36.7oC and heart rate was 112 bpm. Upon heart auscultation, grade 3 murmur could be heard at the 3 ~ 4 intercostal space to the left of the sternum. Routine blood examination revealed white blood cells (WBC): 13.98 × 109 with a ratio of 91.1%; erythrocyte sedimentation rate (ESR): 80 mm/h, C reactive protein (CRP): 91.7 g; procalcitonin (PCT): 9.37 ng/mL, antistreptococcal antibody (ASO): 144. Hemolytic Streptococcus sensitive to vancomycin was cultured from the blood. Cardiac color Doppler ultrasound examination indicated a possibility of ascending aortic stenosis, infective endocarditis, and reduced function of the heart. Computed tomography examination showed ascending aortic stenosis and infective aneurysm involved in the ascending aorta, aortic arch, brachiocephalic trunk, left common carotid artery, and left subclavian artery (Figure 1). Intraoperative femoral artery and superior inferior vena cava intubation was performed to establish a cardiopulmonary bypass, while maintaining a body temperature of 28oC. After blocking the aorta, the non-coronal sinus was split and enlarged by a Gore-Tex vessel to build a new aortic root. Subsequently, a 20-mm Gore-Tex artificial blood vessel was used to replace the ascending aorta, and an 18-mm Gore-Tex three-branch vessel was employed to instead of the active artery arch. During the operation, the aortic wall tissue was sent to the pathological examination. It revealed the formation of a fibrous thrombus-like substance and infiltration of numerous lymphocytes, plasma cells, and granulocyte in the aortic wall. During the perioperative period, the patient was administered vancomycin for 6 weeks. Cardiac color Doppler ultrasound and CT examination of anastomotic stoma were regularly performed to evaluate the recoverment, which showed that the patient’s cardiac function was improved significantly. The incidence of infective endocarditis due to a congenital heart defect is 6% 24% (2). Infective endocarditis often occurs in the aortic valve, but it rarely affects the ascending aorta and the aortic arch. Infective endarteritis is typically seen in patients with aortic coarctation and silent patent ductus arteriosus. Staphylococcus aureus and Streptococcus viridans are the most common infecting organisms (1). This patient was diagnosed with severe ascending aortic stenosis in our hospital two years ago and had no lesion in the aortic valve. In this hospitalization, alpha hemolytic Streptococci were cultured from the blood and the pathological examinations of the vascular wall tissues showed a large number of neutrophil infiltrations. Therefore, we considered this a case of aortic inflammation caused by ascending aortic stenosis. As we know, this is the first patient of infective endarteritis caused by the isolated ascending aortic stenosis. Ascending aorta and aorta arch replacement is widely used in adult aortic dissections. In children, it is mainly used for those with ascending aorta dilation caused by connective tissue disease or Ross surgery (3). However, due to the lack of growth in the tissues after replacement, its use in children is limited. In 2003, Carrel (3) reported that