Operative Management
All cases were performed with median sternotomy. Myocardial protection was moderate systemic hypothermia with primarily retrograde cold blood cardioplegia given every twenty minutes.
Infection extension over the left atrial roof commonly occurred and was debrided completely including the aorto-mitral curtain if necessary. Penetration into the ventricular septum was aggressively debrided down to healthy looking muscle. Rebuilding the heart depended on how much was removed. With mitral valve involvement, valve repair or replacement was performed before proceeding to the root reconstruction. The left atrial roof and curtain was rebuilt with autologous or bovine pericardial tissue.
Sizing of the aortic homograft was performed on the basis of echo measurement of the aortic annulus and directly. If all sizes were available, the largest possible size was chosen.
Interrupted 4-0 polypropylene sutures were placed around the debrided aortic root and curtain. Incorporating a 5 mm wide strip of bovine pericardium on the outside of the root added strength and hemostasis so each stitch was passed through the pericardium as it was placed. The sutures were placed through the homograft from the inside out. The homograft was oriented anatomically with donor mitral matching recipient aortomitral curtain and the sutures were tied.
Coronary buttons were reimplanted into the sites of the homograft coronary stumps with continuous 5-0 polypropylene. The distal end of the homograft was trimmed and sewn to the native aorta with continuous 4-0 polypropylene.
In the majority of the patients, the hemostasis was expected to be challenging due to the combination of the preoperative deconditioning due to infection, friable tissue, and technically demanding and lengthy operation. Therefore, a Cabrol patch with Cooley fistula was often applied preemptively. This was performed with a large patch of bovine pericardium sewn to the homograft superiorly, right ventricle outflow tract and right atrium inferiorly, the main pulmonary trunk medially, and superior vena cava laterally, creating a closed space around the root. A small right atriotomy was made before closing this closed space, creating a perigraft to right atrium shunt.
Postoperative conduction disorder was highly expected due to radical debridement of infective tissue, so permanent epicardial pacing electrodes were often preemptively placed.