Management of rheumatic aortic valve disease using the Ozaki procedure with autologous pericardium: a case report

Background Rheumatic valve disease (RVD) is the most common cause of cardiovascular death in low-middle income nations. Surgical aortic valve (AV) interventions for RVD, especially in children, have proven problematic with graft failure, relapse, and poor compliance with anticoagulation. A novel technique involving neocuspidization of the aortic annulus using autologous pericardium to construct new AV leaflets (the Ozaki procedure) has shown promising outcomes in children with congenital AV disease; however, there are no previous recorded cases using this technique in children with RVD. Case summary We present the case of a 15-year-old male presenting with exertional angina and dyspnoea with a background of previous rheumatic fever. Echocardiography had shown a regurgitant tricuspid AV, left ventricular dilatation with mitral valve leaflet tethering. The patient underwent the Ozaki procedure for his AV regurgitation and was discharged following an uneventful post-operative recovery. The patient had full resolution of symptoms following the procedure and remains well 3 years following his operation. Discussion This case highlights that good outcomes with the Ozaki procedure in RVD are possible 3-years post-operatively and should prompt future studies to evaluate the procedure as a surgical option for paediatric patients in this clinical context. Additionally, the Ozaki procedure may also provide a cost-effective surgical technique requiring minimal additional operative resources and reduced follow-up demand, which would be critical in low-resource clinical settings where RVD is prevalent.

P24: MANAGEMENT OF RHEUMATIC VALVE DISEASE OF THE AORTIC VALVE USING THE OZAKI PROCEDURE WITH AUTOLOGOUS PERICARDIUM

Case-Study A 15-year-old boy was referred to our tertiary centre from his local paediatric services with a background of rheumatic fever, severe aortic regurgitation (AR) and mild to moderate mitral regurgitation. He had a history of angina and dyspnoea on exertion, a 2/6 ejection systolic murmur and 2/4 end diastolic murmur. Transthoracic echocardiography showed severe aortic valve insufficiency (with flow reversal seen in the descending aorta and an LV end diastolic volume of 173 ml/m2) and trivial pulmonary valve regurgitation. Autograft failure following the favoured Ross procedure deemed the patient as a candidate for an Ozaki procedure. Autologous pericardium was used to replace the diseased aortic valve. Intraoperative transoesophageal echocardiography showed a deficient left coronary cusp leaflet and a retracted right coronary cusp leaflet. The patient was under cardiopulmonary bypass for 124 minutes and on cross-clamping for 99 minutes with no intraoperative complications. Histological examination of the aortic valve leaflets showed neovascularisation, myxoid changes and disarray of the fibrous stroma. Postoperative recovery was uneventful. The postoperative echocardiogram showed trivial AR, end diastolic volume 217ml, end systolic volume 12 ml and 40% ejection fraction. There was full resolution of the dyspnoea, angina and diastolic murmur on follow-up 4-months postoperatively as supported by healthy valve function on echocardiography. This case highlights that in those of risk of multiple valve pathology, such as in rheumatic valve disease, an Ozaki procedure using autologous pericardium is a viable surgical option for paediatric aortic valve repair with good outcomes. Take-home message In cases of systemic conditions affecting the heart valves where there is multiple valve pathology and risk of autograft failure, such as rheumatic valve disease, the use of autologous pericardium to replace these valves has shown to be a viable option in this paediatric case.

Bartonella Species as a Cause of Culture-negative Endocarditis in South Africa

Background: Previous reports have highlighted the high prevalence of blood culture negative endocarditis (BCNE) in South Africa.Methods: The Tygerberg Endocarditis cohort (TEC) study is a prospective cohort study of patients with confirmed or suspected IE presenting to Tygerberg Academic Hospital, Cape Town, South Africa. Results: To date, 44 patients have been included in this ongoing study. Fourteen of the 44 patients (31.8%) had BCNE. Further analysis of the patients with BCNE identified Bartonella species as the most common causative organism (n=6; 43%). Other causes included Mycoplasma species (n=2), C. burnetii (n=1), and non-bacterial thrombotic endocarditis due to anti-phospholipid syndrome (n=1). No cause could be identified in 4 of the 44 patients (9%). Bartonella quintana was identified with PCR of valvular tissue as the causative organism in 4 of the 5 patients that underwent urgent surgery. The patients with Bartonella IE (n=6) had an average age of 39 years with equal gender distribution The common clinical features were clubbing (n=5; 83%), anemia (n=4; 66.6%), haematuria (n=3; 50%), acute on chronic severe valvular lesion (n=3; 50%) and acute severe valvular lesion (n=2; 33.3%). The aortic valve was involved in 5 of 6 patients. During a mean follow-up period of 251 days after diagnosis, no major adverse events occurred.Conclusion: Bartonella IE is an important cause of BCNE in the Western Cape of South Africa. Imaging findings of significant valvular destruction with large vegetations on the aortic valve not affected by pre-existing congenital or rheumatic valve disease, should raise the suspicion of Bartonella IE.

Thrombocytopenia Induced by Giant Atrial Thrombus in Rheumatic Valve Disease- A Case Report

We report a 52-year-old and weight of 79.36 lbs female patient with Thrombocytopenia induced by giant atrial thrombus in rheumatic mitral stenosis. The patient underwent bioprosthetic mitral valve implantation and removal of the giant thrombus. The platelet count progressively increased achieving normal levels one week after surgery. Cardiovasc. j. 2020; 13(1): 95-96

Infectious Endocarditis in Sub-Saharan Africa: Epidemic-Clinical Aspects, Evolutionary and Prognostic: Multicentre Study on 81 Cases Followed Over 1 Year in Lomé (Togo)

Introduction: Infectious endocarditis remains a relatively common, serious pathology and suffering heavy mortality in sub-Saharan Africa. Purpose: The objective of this study was to describe the epidemic-clinical, evolutionary aspects patients hospitalized for infectious endocarditis and assess their prognosis. Methods: This is a prospective, 5-year, multicentre study of 81 hospitalized patients and treated for infectious endocarditis. These patients were followed for at least a year. Results: We observed that in our sub-Saharan context, patients who suffer from infectious endocarditis are often young, with an average age of 30 years. Rheumatic valve disease and congenital heart disease underlying the most frequent. Blood cultures are often negative, making it difficult the choice of appropriate antibiotic therapy. Surgical treatment (heart surgery) is difficult to access (2% in our study). As a result, the mortality is very high (63% at 1 year), with a survival rate of only 37% at 1 year. Conclusion: Our study shows that despite progress in diagnosis and therapeutic management, infectious endocarditis remains a pathology serious with heavy mortality in sub-Saharan Africa. It is important to highlight the importance of prevention, early diagnosis of infectious endocarditis, and especially the need for early medical-surgical management of these patients to improve their prognosis.

Giant right atrium: a long-term complication of rheumatic heart disease

Giant right atrium (RA) is a rare entity often seen during childhood due to congenital anomalies. Limited literature has reported such finding in patients with rheumatic valvular heart disease. Here we present a case of a 68-year-old female with a history of rheumatic valve disease treated with a Starr Edwards mechanical ball-in-cage mitral valve replacement and tricuspid valve annuloplasty ring procedures. The patient developed heart failure and had multiple hospital admissions over three decades for heart failure exacerbations mostly triggered by medication and dietary non-compliance. She eventually developed a giant RA that filled most of her thorax. This case demonstrates an extreme form of cardiac remodeling caused by long-term rheumatic valvular heart disease.