Commentary: Biologic mustache for the modified Cabrol technique

Central MessageRedo surgery for prosthetic valve endocarditis can be technically challenging with a high risk of recurrent infection. Consideration of an optimal technique with biologic materials is essential.See Article page 65. Redo surgery for prosthetic valve endocarditis can be technically challenging with a high risk of recurrent infection. Consideration of an optimal technique with biologic materials is essential. See Article page 65. Prosthetic valve endocarditis (PVE) is a serious complication of valve replacement. In the aortic position, PVE carries a high risk of paravalvular abscess formation and total aortic root destruction. In such situations, redo surgery can be technically challenging, and may be associated with a high risk of recurrent prosthetic valve infection. Thus, consideration of an optimal surgical technique to avoid the risk of reinfection is essential. Guenther and colleagues1Guenther T.M. Godoy L. Chen S.A. Rodriguez V.M. Homograft aortic root replacement with modified Cabrol extension using cryopreserved femoral artery for bioprosthetic aortic valve endocarditis.J Thorac Cardiovasc Surg Tech. 2020; 4: 65-67Google Scholar report an interesting and elegant method of aortic root replacement for PVE complicated by extensive root abscess and poorly mobile coronary arteries. They perform a homograft aortic root replacement and reimplantation of the 2 coronary ostia by a modified Cabrol extension via a cryopreserved femoral artery. Concomitantly, the eroded aortomitral continuity is re-established with a bovine pericardial patch and the anterior mitral valve leaflet is resuspended. Some specific aspects of their procedure deserve to be highlighted. Although the Cabrol technique was developed to handle situations in which mobilization of coronary buttons is unachievable without damage or increased tension, this approach may carry a risk of pseudoaneurysm formation and, more importantly, kinking of the coronary graft and occlusion.2Gelsomino S. Frassani R. Da Col P. Morocutti G. Masullo G. Spedicato L. et al.A long-term experience with the Cabrol root replacement technique for the management of ascending aortic aneurysms and dissections.Ann Thorac Surg. 2003; 75: 126-131Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar This risk may, theoretically, be even higher with the modified technique performed by Guenther and colleagues,1Guenther T.M. Godoy L. Chen S.A. Rodriguez V.M. Homograft aortic root replacement with modified Cabrol extension using cryopreserved femoral artery for bioprosthetic aortic valve endocarditis.J Thorac Cardiovasc Surg Tech. 2020; 4: 65-67Google Scholar due to the left-sided placement of the left coronary graft between the neoaorta and pulmonary artery, instead of a more direct route from the right side of the aorta as in the classic technique. Nevertheless, the specific situation of an aneurysmal native aorta seems to attenuate this risk, and has led the authors to adopt this modification with good results. The role of targeted cross-sectional imaging in the preoperative planning of these complex procedures is also emphasized. The authors highlight the relevance of homograft aortic root replacement as a valuable alternative to the use of prosthetic material in the setting of extensive tissue destruction in PVE, with very low rates of recurrent infection.3Musci M. Weng Y. Hübler M. Amiri A. Pasic M. Kosky S. et al.Homograft aortic root replacement in native or prosthetic active infective endocarditis: twenty-year single-center experience.J Thorac Cardiovasc Surg. 2010; 139: 665-673Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar However, homografts are not readily available at every institution, especially for urgent operations. In this setting, xenograft bioconduits are an excellent off-the-shelf alternative with very good outcomes.4Roubelakis A. Karangelis D. Sadeque S. Yanagawa B. Modi A. Barlow C.W. et al.Initial experience with xenograft bioconduit for the treatment of complex prosthetic valve endocarditis.Perfusion. 2017; 32: 383-388Crossref PubMed Scopus (0) Google Scholar The authors remind readers that reoperation for PVE is among the more daunting operations that cardiac surgeons face, and that rigorous preoperative planning and the availability of multiple contingency strategies in a surgeon's armamentarium is essential, not only for a viable patient at the end of the surgery, but also for the prevention of future reinfection. Homograft aortic root replacement with modified Cabrol extension using cryopreserved femoral artery for bioprosthetic aortic valve endocarditisJTCVS TechniquesVol. 4PreviewProsthetic valve endocarditis (PVE) is a serious complication after aortic valve replacement, with a mortality rate between 18% and 30%.1 Although some patients can be effectively managed with prolonged courses of antibiotics, surgical indications exist and include abscess formation, development of heart block or failure, persistent bacteremia, and infection with certain organisms, such as fungi and certain virulent bacteria.2 Operative intervention entails resection of infected/necrotic material, drainage of associated abscesses, and commonly aortic root reconstruction. Full-Text PDF Open Access

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