a 61-year - old man complaining of syncope and chest pain came to our hospital .
ten days prior to hospitalization , he had had a fever , chills , and body ache .
he had taken some medication from a local clinic for these symptoms , which were supposedly caused by a simple upper respiratory infection . despite the medication ,
the patient had developed another symptom of syncope 7 days earlier and was transferred to the neurology department for evaluation . on arrival , he had mild fever ( 37.5c ) with chills , sweating , and dyspnea .
the blood pressure was 110/40 mmhg , pulse rate 90/min , and respiratory rate 20/min . on the chest auscultation ,
the chest x - ray revealed cardiomegaly , and the electrocardiogram demonstrated a complete av block . in the brain magnetic resonance imaging
, there were multiple infarcts , which were thought to be caused by septic emboli .
cardiopulmonary bypass was initiated , and the ascending aorta was then cross - clamped . after infusing the histidine - tryptophan - ketoglutarate solution through the retrograde cardioplegic catheter and local cooling with ice slush , transverse aortotomy was performed .
the aortic valve was thickened and retracted ; this was consistent with a rheumatic aortic stenosis .
there was a commissural fusion between the noncoronary cusp and the right coronary cusp , which also had fibrous thickening with calcification and abscess ( fig .
1 ) . the periannular abscess involved the aortic root of the base of noncoronary sinus ( fig .
2 ) and invaded down to the central fibrous body , whole membranous septum , and mitral and tricuspid valves ( tvs ) ( fig .
the aortic valve was excised carefully , and then , the infected tissue and the pus were removed meticulously from the abscess pocket down to the membranous septum , central fibrous body , annulus of the mitral valve ( mv ) , and anteroseptal commissure of the tv .
we also made an extended transseptal incision extending from the right atrial auricle to the tv to expose the lesion and achieve complete debridement .
the septal and anterior leaflets of the tv were also partially resected due to vegetations . after the complete debridement of the infected area , we found a large defect including the left ventricular outflow tract ( lvot ) , which contained the membranous septum , central fibrous body extending to the tv , and mitral annulus .
the reconstruction of the lvot was performed with half - folded elliptical bovine pericardium ( peri - guard ; synovis surgical innovation , st .
the bovine pericardium was trimmed into an elliptical shape and a half - fold was made ; then , its base was secured by interrupted suturing to the annulus of the mv by using reinforcement with a teflon felt , followed by lvot reconstruction using a leaflet of the half - folded elliptical bovine patch with aortic valve implantation concomitantly using a 21-mm mechanical valve ( sjm masters series valve ; st .
3 ) . after closing the aortotomy site , tricuspid annuloplasty was done : partial excision and re - suspension of the septal and the anterior leaflet and anteroseptal commissuroplasty .
the other half of the half - folded elliptical bovine patch was used for repairing the right atrial wall with a defect and tv . after weaning the patient from cardiopulmonary bypass
, we conducted transesophageal echocardiography , which revealed neither an intracardiac shunt nor tv and mv regurgitation . because the complete av block was observed , we began temporary pacing at the rate of 80 beats / min after placing permanent pacing leads on the right atrial and ventricular walls .
the total cardiopulmonary bypass and aortic cross clamping times were 303 minutes and 238 minutes , respectively .
on postoperative day 1 , we were able to wean the patient from mechanical ventilation and extubate an endotracheal tube .
intravenous antibiotics with ampicillin , nafcillin , and gentamicin were continued for approximately 6 more weeks .
the echocardiography on postoperative day 51 revealed normal lv contractility , no intracardiac shunt , and a well - functioning prosthetic mechanical aortic valve without para - valvular leakage and tricuspid regurgitation . on postoperative day 56
infective endocarditis with abscess formation is a rare , life - threatening condition , and it exhibits a high postoperative mortality .
this medical condition is fatal because of the complicated anatomical features of the fibrous skeleton .
this is also particularly true when the fibrous skeleton of the heart is extensively destroyed and the reconstructive procedures are complicated .
the fibrous skeleton of the heart is a complex framework that surrounds the orifices of the valves , the right and left fibrous trigone , and the membranous parts of the interatrial and interventricular septa .
our case displayed fibrous skeleton destruction , which extended even to the mv and tv .
after the meticulous debridement and resection of all infected and necrotic tissues , an appropriate reconstruction of defects ensured better surgical results . unfortunately , current literature regarding the surgical management of fibrous skeleton destruction is limited . in the presence of endocarditis , annular destruction with a loss of ventricular or mitral aortic continuity
david et al .   described a surgical method that involves replacing aortic and mvs after the reconstruction of the intervalvular fibrous body by using two triangular patches of glutaraldehyde - fixed bovine pericardium .
they insisted that the glutaraldehyde - treated bovine pericardium is an excellent material for use in reconstructing the heart in patients with paravalvular abscess .
presented a case of a combination of annuloaortic ectasia and infectious endocarditis that required reconstruction of the aortic root and aorto - mitral common annulus , and mitral valve replacement .
black et al .   reported that konno aorto - ventriculoplasty , originally described for the enlargement of the aortic annulus and the lvot , may be well suited for the debridement and repair of fibrous skeleton endocarditis .
we present a case of the destructed fibrous skeleton  including lvot , right fibrous trigone , membranous septum , and tricuspid and mitral annulus  which we successfully reconstructed with a bovine pericardial patch that had a half - folded elliptical shape .
one leaflet of this patch was applied for lvot reconstruction from the mv with aortic valve implantation , and the other for the right atrial wall with a defect and tv . in conclusion , in the reconstruction of the lvot with a defect , right fibrous trigone , and tv in the infective endocarditis
, one half - folded elliptical pericardial patch could be a useful option to repair both the lvot and the right - side area with a defect .
 a 61-year - old man was diagnosed with aortic stenoinsufficiency with periannular abscess , which involved the aortic root of noncoronary sinus ( ncs ) that invaded down to the central fibrous body , whole membranous septum , mitral valve ( mv ) , and tricuspid valve ( tv ) . 
 the open complete debridement was executed from the aortic annulus at ncs down to the central fibrous body and annulus of the mv and the tv , followed by the left ventricular outflow tract reconstruction with implantation of a mechanical aortic valve by using a leaflet of the half - folded elliptical bovine pericardial patch . 
 another leaflet of this patch was used for the repair of the right atrial wall with a defect and the tv . 
CASE REPORT
DISCUSSION