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\begin{document}

\title{Successful drainage of periaortic graft abscess and transcatheter aortic
valve replacement in the same setting - a hybrid approach.}



\author[1]{Ahmed S. Nasser}%
\author[2]{Osama Elkhateeb}%
\author[3]{Keir Stewart}%
\author[3]{Hashem Aliter}%
\affil[1]{Dalhousie University Faculty of Medicine}%
\affil[2]{Dalhousie University Department of Medicine}%
\affil[3]{Dalhousie University Division of Cardiac Surgery}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{english}
\begin{abstract}
81-year-old man with a history~of~Bio-Bentall surgery presented to the
emergency department with fever, chills and back pain. Initial physical
examination was inconclusive apart from sudden onset of delirium, and
investigation showed elevated WBCs, anemia, and neutrophilia. Further
studies revealed gram-positive cocci on the initial blood culture, which
was then confirmed to be MSSA bacteremia. Subsequently, a TEE showed a
peri-aortic abscess, Moderate AR and severe AS with no evidence of
endocarditis. Antibiotics were started and urgent abscess drainage was
planned. In a hybrid operative setting, a multidisciplinary team of
cardiology, and cardiac surgery managed the periaortic graft abscess
drainage~through a median sternotomy and TAVR. Post-operatively, the
complications included bradycardia, and RHF. Six-week course of IV
Rifampin, Probenecid and Cefazolin was initiated, and patient was to
remain on lifelong Cefadroxil.%
\end{abstract}%



\sloppy


\textbf{TITLE:} Successful drainage of periaortic graft abscess and
transcatheter aortic valve replacement in the same setting - a hybrid
approach.

\textbf{Running title:} Hybrid approach to periaortic abscess.

\textbf{AUTHORS:} Ahmed S. Nasser M.D. \textsuperscript{a}, Osama El
Khateeb M.D. \textsuperscript{b}, Keir Stewart M.D. \textsuperscript{c},
Hashem Aliter M.D., Ph.D. \textsuperscript{c}

\textbf{AFFILIATIONS:}

\textsuperscript{a} Dalhousie University, Halifax, NS, Canada.

\textsuperscript{b} Division of Cardiology, Department of Medicine,
Dalhousie University, Halifax, NS, Canada.

\textsuperscript{c} Division of Cardiac Surgery, Department of Surgery,
Dalhousie University, Halifax, NS, Canada

\textbf{Conflicts} : The authors have nothing to disclose.

\textbf{Funding:} None of the authors received grants, contracts, or
financial support.

\textbf{Consent:} Patient consent was taken for this report.

\textbf{Hospital Ethics board approval was granted for this report.}

\textbf{Total word count:} 1170 (body), 1561 (all inclusive).

\textbf{CORRESPONDING AUTHOR:}

\textbf{Ahmed S. Nasser}

\textbf{Address for correspondence}

QEII Health Science Center, Dalhousie University.

Room 3261, Victoria Building, 1276 South Park Street, Halifax, NS B3H
2Y9.

Tel: (902) 440 8644

Ahmed.nasser@dal.ca

\textbf{ABSTRACT}

81-year-old man with a history~of~Bio-Bentall surgery presented to the
emergency department with fever, chills and back pain. Initial physical
examination was inconclusive apart from sudden onset of delirium, and
investigation showed elevated WBCs, anemia, and neutrophilia. Further
studies revealed gram-positive cocci on the initial blood culture, which
was then confirmed to be MSSA bacteremia. Subsequently, a TEE showed a
peri-aortic abscess, Moderate AR and severe AS with no evidence of
endocarditis. Antibiotics were started and urgent abscess drainage was
planned. In a hybrid operative setting, a multidisciplinary team of
cardiology, and cardiac surgery managed the periaortic graft abscess
drainage~through a median sternotomy and TAVR. Post-operatively, the
complications included bradycardia, and RHF. Six-week course of IV
Rifampin, Probenecid and Cefazolin was initiated, and patient was to
remain on lifelong Cefadroxil.

\textbf{KEYWORDS}

Aortic valve replacement, hybrid operating room, aortic graft infection,
TAVR.

\textbf{HISTORY OF PRESENTATION}

An 81-year-old male with a history of Bio-Bentall procedure~performed~13
years ago presented to the emergency department with the chief
complaints of fever, chills, and flank pain. The~patient was previously
an active individual who acutely developed symptoms of bilateral flank
pain, weakness, fever, and chills a week before admission,~and~nausea
with no vomiting two days prior to admission.~Upon examination, vital
signs were stable and there were no other significant findings on
systematic review.

\textbf{PAST MEDICAL HISTORY}

Patients' medical history~was relevant for~a surgically repaired
ascending aorta aneurysm using~a 30 mm Gelweave graft and aortic valve
replacement with a 23 mm CE pericardial tissue valve (Edwards
Lifesciences, Irvine, CA, USA) with reimplantation of coronary
arteries.~The patient also had underlying~hypertension, and aortic
pseudo-coarctation \textbf{(Figure 1A),} prostate cancer, and chronic
atrial fibrillation.

\textbf{DIFFERENTIAL DIAGNOSIS}

Kidney stone, acute pyelonephritis, septic pulmonary emboli, and
infective endocarditis were part of the differential diagnosis.

\textbf{INVESTIGATION}

The patient's blood work showed~leukocytosis,~normocytic anemia,
elevated creatinine, and the presence of RBCs, nitrites, and proteins on
urinalysis. A chest X-ray ruled out any lung pathologies. A CT chest
(\textbf{Figure 2B)} , abdomen and pelvis ruled out renal or pulmonary
pathologies and was started on Ceftriaxone~1g IV. Initial blood culture
revealed gram-positive cocci for which Piperacillin-Tazobactam~3.375g
q6h IV~(Pip-Tazo) was added to the treatment. Subsequently, the blood
cultures showed Methicillin Sensitive Staph Aureus (MSSA) bacteremia and
therapy was changed to Vancomycin~2g IV loading dose followed by 1250mg
IV q12h and Cefazolin 2g IVq8h. The patient had a~transthoracic
echocardiogram (TTE) which~demonstrated moderate aortic regurgitation
and severe aortic stenosis with bi-atrial enlargement. However, the
transesophageal echocardiography (TEE) showed a well loculated large
area of echo-dense material around the aortic valve~consistent~with a
peri-aortic abscess \textbf{(Figure 2A)} with no evidence of
endocarditis. Cardiac catheterization was normal.

\textbf{MANAGEMENT}

Patient was admitted to the Internal medicine floor and Infectious
diseases team were consulted, they concurred with the current treatment
plan of Cefazolin and Vancomycin. After the TEE findings and normal
cardiac catheterization, we decided to move forward with surgery. Due to
the patient's co-morbid status, Euro score of 15\% and high mortality
risk, it was deemed that the surgery should take place in a hybrid
operating room setting. The patient underwent surgery - a
redo-sternotomy in the standard fashion- and a large abscess cavity was
seen surrounding the aortic graft. Following the abscess drainage, the
cavity was washed with antibiotic solution with placement of antibiotic
beads around the graft, and the sternum was closed. The bacterial
culture of pus and tissue collected during the surgery was negative.

The heart team performed a Trans Catheter Aortic Valve Implantation
(TAVI) valve in valve procedure \textbf{(Figure 1B)} and \textbf{(Video
1)} . A 14 French pro-glide sheath and a 6 French pro-glide sheath were
used in the right and left femoral arteries respectively. A Medtronic
CoreValue Evolut R 26 mm valve (CoreValve, Medtronic, Luxembourg) was
used. Post-operative ECHO showed a well-seated aortic valve with a mean
gradient of 8 mmHg and no leaks noted \textbf{(Figure 2C)}
and\textbf{(Video 2)} .

Postoperatively, the patient's recovery was complicated with right heart
failure (RHF) and symptomatic bradycardia that resolved. It was decided
that the patient will remain on lifelong suppressive antibiotic therapy
with daily Cefadroxil 1gm orally.

\textbf{FOLLOW-UP}

After six months, a routine follow-up ECHO showed a normally functioning
bioprosthetic valve with a slightly increased thickness of the aortic
root that was presumed to be secondary to the inflammatory process from
debridement of the abscess. No stenosis or regurgitation was seen, and
LV and RV systolic functions were normal.

\textbf{DISCUSSION}

Infections of the aortic grafts are rare postoperative complications of
aortic surgeries. They could happen in the early postoperative course
or, as in our case, later years after surgery. Although the incidence
varies between 1-5\%~based on center and surgeon~expertise, the
condition can be challenging and associated with a high mortality
rate\textsuperscript{{[}1, 2{]}}. Due to its complexity and~rarity, the
predisposing factors for aortic graft infection are yet to be
extensively identified by studies \textsuperscript{{[}3{]}}. Although
the source of graft infection following the cardiac surgery procedure
remains unknown, skin flora is considered the most common source of
infection \textsuperscript{{[}3{]}}. Early postoperative infections are
considered from direct skin flora contamination, whereas delayed
infection might be due to hemostatic agents, nosocomial septicemia, and
immunocompromised states \textsuperscript{{[}4{]}}. In our case the most
likely predisposing factor for the patient was the immunocompromised
state secondary to the treatment of prostate cancer.

Symptoms of aortic graft infection are often vague, and this requires a
high degree of suspicion from the clinician when treating patients with
pre-existing aortic grafts. It could present as a myriad of vague
symptoms, including: fever, malaise, weight loss, back pain,
leukocytosis, or abdominal pain.~Computerized tomography (CT) with
contrast enhancement is the diagnostic modality of choice in aortic
graft infections \textsuperscript{{[}5{]}}.

The EuroScore is a simple and quick way to assess patients' risk of
mortality. Our patient had a score of 15\%, which directly correlates to
a 15\% chance of postoperative death. Our patient also had multiple risk
factors such as advanced age, urgent nature of procedure and history of
previous cardiac surgery and anemia. Although anemia is not part of the
EuroScore, studies have noted an increased mortality associated with
pre-operative anemia especially in the setting of open heart
surgery\textsuperscript{{[}6{]}}. Our patient was managed in a hybrid
operating room setting, where the patient first underwent drainage of
their peri-aortic abscesses in a surgery that carries a mortality risk
ranging between 19 to 25\%. Subsequently, they underwent a TAVR.
Post-operatively, the patient was transferred to Cardiovascular ICU and
managed in the standard fashion.

The surgical management of acute graft infection depends on the degree
and extent of infection. The~general~belief is~that if the graft and
autologous tissue were still surrounded by healthy tissue, the survival
rate was higher if the vascular prosthesis was not
removed\textsuperscript{{[}3, 7{]}}. In our case, the graft was not
infected, there were no signs of endocarditis and existing prosthetic
grafts could be salvaged, so only local debridement was performed
followed by placement of antibiotic beads around the graft site.

As previously mentioned, TAVR has become a game changer in the field of
aortic valve surgery and thanks to this approach we were able to
successfully treat a critically ill patient in a multi-disciplinary
setting.

\textbf{CONCLUSION}

Even though graft infection rates are very low, they carry a high risk
of morbidity and mortality due to the surgical nature of the procedure
and risk of infection. This case report highlights that a streamlined
and strong interdisciplinary approach can minimize the risk of intra and
post-operative death in high-risk patients. Additionally, this report
further strengthens the existing data on importance of Valve in Valve
TAVR for moderate to extremely high-risk patients and enumerates the
importance of considering and implementing a hybrid approach for
patients with high morality risks in the field of cardiovascular
medicine as it offers the best available combination of treatments.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  K. Laohapensang, S. Arworn, S. Orrapin, T. Reanpang, and S. Orrapin,
  ``Management of the infected aortic endograft,'' \emph{Seminars in
  Vascular Surgery}, vol. 30, no. 2--3, pp. 91--94, Jun. 2017, doi:
  10.1053/j.semvascsurg.2017.11.001.
\item
  R. O. Darouiche, ``Treatment of Infections Associated with Surgical
  Implants,'' \emph{N Engl J Med}, vol. 350, no. 14, pp. 1422--1429,
  Apr. 2004, doi: 10.1056/NEJMra035415.
\item
  T. Shiraev \emph{et al.}, ``Incidence, Management, and Outcomes of
  Aortic Graft Infection,'' \emph{Annals of Vascular Surgery}, vol. 59,
  pp. 73--83, Aug. 2019, doi: 10.1016/j.avsg.2019.01.027.
\item
  E. Ducasse, A. Calisti, F. Speziale, L. Rizzo, M. Misuraca, and P.
  Fiorani, ``Aortoiliac Stent Graft Infection: Current Problems and
  Management,'' \emph{Annals of Vascular Surgery}, vol. 18, no. 5, pp.
  521--526, Sep. 2004, doi: 10.1007/s10016-004-0075-9.
\item
  P. Rossi \emph{et al.}, ``Prosthetic Graft Infection: Diagnostic and
  Therapeutic Role of Interventional Radiology,'' \emph{Journal of
  Vascular and Interventional Radiology}, vol. 8, no. 2, pp. 271--277,
  Mar. 1997, doi: 10.1016/S1051-0443(97)70554-2.
\item
  M. Ranucci, U. Di Dedda, S. Castelvecchio, L. Menicanti, A. Frigiola,
  and G. Pelissero, ``Impact of Preoperative Anemia on Outcome in Adult
  Cardiac Surgery: A Propensity-Matched Analysis,'' \emph{The Annals of
  Thoracic Surgery}, vol. 94, no. 4, pp. 1134--1141, Oct. 2012, doi:
  10.1016/j.athoracsur.2012.04.042.
\item
  P. Tossios \emph{et al.}, ``Treatment of Infected Thoracic Aortic
  Prosthetic Grafts with the In Situ Preservation Strategy: A Review of
  its History, Surgical Technique, and Results,'' \emph{Heart, Lung and
  Circulation}, vol. 23, no. 1, pp. 24--31, Jan. 2014, doi:
  10.1016/j.hlc.2013.09.001.
\end{enumerate}

\textbf{LEGEND}

\textbf{ABBREVIATIONS}

Transthoracic echocardiogram (TTE), Transesophageal echocardiography
(TEE), Trans Catheter Aortic Valve Implantation (TAVI), Transcatheter
Aortic Valve Replacement (TAVR), Echocardiogram (ECHO), Right heart
failure (RHF), RV (Right ventricle), LV (left ventricle)

\textbf{FIGURE TITLES AND CAPTIONS}

\textbf{Figure 1 A.} Pseudo-coarctation of the tortuous thoracic aorta
just distal to the arch. \textbf{B.} TAVR valve in valve.

\textbf{Figure 2 A.} TEE showing aortic root abscess (white arrow
marks). \textbf{B.} Coronal CT showing aortic root abscess (white arrow
mark). \textbf{C.} Post-op ECHO showing no paravalvular

leaks.

\textbf{Video 1:} TAVR - valve in valve procedure.

\textbf{Video 2:} Follow-up ECHO four months post-operative.\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

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\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`Video 1.mp4`  available at \url{https://authorea.com/users/489623/articles/573274-successful-drainage-of-periaortic-graft-abscess-and-transcatheter-aortic-valve-replacement-in-the-same-setting-a-hybrid-approach}

\textbf{Hosted file}

\verb`Video 2.mp4`  available at \url{https://authorea.com/users/489623/articles/573274-successful-drainage-of-periaortic-graft-abscess-and-transcatheter-aortic-valve-replacement-in-the-same-setting-a-hybrid-approach}

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