Infective endocarditis with perivalvular abscess following sutureless valve implantation, successfully treated with aortic root reconstruction and biological Bentall procedure | Journal of Cardiothoracic Surgery | Full Text

Journal of Cardiothoracic Surgery volume 20, Article number: 279 (2025) Cite this article

Aortic valve prosthetic infections can lead to the spread of infection, causing annular abscesses and annular destruction, which may require annular reconstruction and aortic root replacement. Reports on the infection and reoperation of sutureless valves are rare. Here, we present a case of infection involving a Perceval sutureless valve, which led to an annular abscess.

We report the case of a 73-year-old woman who had previously undergone sutureless valve implantation for severe stenosis of a bicuspid aortic valve. Approximately 23 months after surgery, the patient developed recurrent Methicillin-resistant Staphylococcus aureus bacteremia and was admitted to the hospital. Following a thorough assessment, she was diagnosed with a prosthetic valve infection and an annular abscess, necessitating surgical intervention. Intraoperatively, significant annular destruction was evident after the valve was removed. The aortic root was reconstructed with a bovine patch and Bentall surgery was accomplished using a composite graft consisting of a biological valve and a Valsalva graft. The patient was discharged in good general condition with no significant post-operative complications.

One of the issues with using a Perceval valve is that in the event of infection, it can lead to the spread of infection from the aortic root to the left ventricular outflow tract, potentially requiring extensive debridement and aortic root replacement.

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Sutureless valves are a newer type of valve with several advantages, including reduced surgical time and minimally invasive implantation [1]. First used in humans in 2007, they received FDA approval in 2013. The Perceval valve, a specific type of sutureless valve, has been rarely associated with infective endocarditis (IE) and annular abscess. Here, we present a rare case of IE associated with abscess formation in a sutureless Perceval valve.

The case involves a 73-year-old female patient with a history of thrombocytopenia, long-term steroid use for over 20 years, and a history of Sjögren's syndrome and hypertrophic cardiomyopathy. The patient underwent AVR with the Perceval M valve (LivaNova PLC, London, UK) for severe aortic stenosis (AS) with bicuspid aortic valve through a median sternotomy, and the postoperative course was uneventful, with no signs of infection, and the patient was discharged. However, 20 months postoperatively, the patient developed Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Antibiotic therapy was initiated, and two months later, blood culture tests became negative. During the initial period of bacteremia, no definite vegetation or abscess was detected by echocardiography. But the patient was readmitted due to recurrent MRSA sepsis at 23 months after surgery. Transesophageal echocardiography showed that the left ventricular ejection fraction was 68%, the mean pressure gradient was 11 mmHg, with no signs of AS or aortic regurgitation (AR). However, a 1 cm vegetation was found at the left coronary cusp (LCC), and the non-coronary cusp (NCC) showed thrombosis with limited opening, along with valve thickening [Fig. 1]. Computed Tomography (CT) imaging revealed an aortic valve abscess, poor aortic valve mobility, and aortic root abscess [Fig. 2(a) (b)]. After 23 months, the patient underwent reoperation.

Preoperative transesophageal echocardiography. Preoperative transesophageal echocardiography showed an approximately 1 cm vegetation on the LCC (a) (orange circle). The NCC showed a thrombus with limited orifice and valve thickening. No AS/AR was observed

Preoperative CT. Preoperative CT showed an abscess at the valve annulus on the LCC side (yellow line: abscess) (a) (b) (green circle: commissural area), with a protrusion of pannus into the LVOT at the end of the valve’s stent frame (c) (red arrow: pannus)

A median sternotomy was performed, and cardiopulmonary bypass was initiated through cannulation of the ascending aorta for arterial inflow and both inferior vena cava and superior vena cava for venous drainage. The aorta was transected above the stented area of the ascending aorta, and the Perceval valve was observed. The stented portion of the Perceval valve was adherent to the sinus of Valsalva and the sinotubular junction. Six Kelly clamps were used to capture the stented protrusion in a hexagonal shape, and the valve was folded and removed. Due to severe adhesion at the aortic root and left ventricular outflow tract (LVOT), careful blunt dissection was performed to avoid tearing the endocardium [Fig. 3(a)(b)]. Although the aortotomy was performed at a higher level than usual to facilitate the explantation of the Perceval valve, it nonetheless offered an adequate and unobstructed view of the annulus afterward. At the LCC valve annulus, an abscess was formed with purulent discharge, with continuity into the LVOT. After removing the Perceval valve, it was found that the annulus and valsalva on the LCC side were destroyed due to infection, and a root reconstruction was necessary. Similarly, the annulus on the right coronary cusp (RCC) side was also destroyed, necessitating root reconstruction. Extensive destruction and active infectious tissue were observed extending continuously from the LCC to the RCC, involving the LVOT, annulus, and sinus of Valsalva. Therefore, we determined that wide resection and reconstruction of the affected tissue were necessary, rather than a localized patch repair with aortic valve replacement. In this reoperative case, adequate pericardial tissue could not be obtained due to previous surgical adhesions. A bovine pericardial patch was used for root reconstruction with double continuous sutures into the myocardial tissue [Fig. 4]. A composite graft was created using a 23 mm Magna Ease biological valve (Edwards Lifesciences, Irvine, CA, USA) and a 28 mm Valsalva graft (Terumo Aortic, Inchinnan, UK), and a Bentall procedure was performed. The sutures for the artificial valve were anchored to the left ventricular myocardium and the pericardial patch with a non-everting mattress suture in a total of 12 sutures. The coronary artery button anastomosis was performed with full-thickness, double-layer sutures, and peripheral anastomosis was done with continuous sutures without felt, considering the risk of infection. No bleeding was observed at the patch site, and no new hematomas or shunt flow were detected around the valve annulus at the end of the surgery. The patient was extubated on the following day, transferred to the general ward on postoperative day (POD) 3, and completed a six-week course of vancomycin for antibiotic therapy. She was discharged on POD 44. Postoperative echocardiography showed no issues with cardiac function, and there was no regurgitation around the artificial valve. Follow-up CT imaging confirmed the resolution of the aortic valve annular abscess.

Intraoperative Findings. The inserted Perceval valve (a) was explanted using Kelly clamps and the aortic intima was dissected (b)

Surgical Procedure. The areas of annulus destruction at the LCC and RCC were repaired with a double continuous suture using a pericardial patch, followed by annular reconstruction

There are few reports on reoperation for IE involving the Perceval valve. In the report by Jarrod Jolliffe on 3196 patients who underwent Perceval valve implantation, the 30-day mortality rate was 2.5%, the 5-year survival rate was 79.5%, permanent pacemaker implantation was required in 7.9%, severe valve regurgitation occurred in 1.6%, structural valve deterioration in 1.5%, stroke in 4.4%, infective endocarditis in 1.6%, and valve explantation in 2.3% [2].

In this case, the cause of the Perceval valve IE was considered to be related to the patient's advanced age and long-term steroid use following open-heart surgery [3]. A method of explanting the valve using two Kelly clamps crossed to form an"X"shape and folding the valve has been previously reported [4]. In this case, the valve had been implanted for two years, leading to adhesion with the endocardium, making the explantation more challenging. The technique of using only two Kelly clamps to perform the X-movement proved insufficient to detach the valve from the adhesions. However, by using six Kelly clamps and manipulating the stented portion in a hexagonal shape, the valve was successfully folded and removed. Given the adhesion to the endocardium, careful dissection was necessary to avoid causing atrioventricular block.

There have been several techniques described for safely and effectively explanting a Transcatheter Aortic Valve Replacement prosthesis, avoiding aortic root injury. Hernandez-Vaquero et al. used an endarterectomy spatula for meticulous dissection, [5] and Valdis et al. employed a heavy snaring suture to collapse the prosthesis and facilitate explantation. [6]

The method used in this case minimized the excessive force applied to the entire valve, making it possible to avoid using a purse-string suture, and it allowed easy modification of the position of the Kelly clamps. This technique may be recommended for the Perceval valve.

Reoperation for prosthetic valve endocarditis (PVE) carries a high surgical mortality rate, and long-term survival is often poor [7, 8]. Failure to perform surgery in a timely manner has been associated with early mortality [8]. Moreover, in PVE patients, destruction of the aortic valve annulus can lead to hemodynamic deterioration, abscess formation, paravalvular leakage, prosthetic valve dysfunction, or uncontrollable sepsis related to conduction abnormalities, which can destabilize hemodynamics [9]. Destruction of the aortic root is associated with early PVE and delayed diagnosis (more than 14 days), but is not correlated with mortality [10]. However, when aortic root destruction is present, the surgical approach may need to be modified, increasing the difficulty of the operation. In such cases, removal of infected tissue and drainage of the abscess cavity, along with aortic valve annulus patch reconstruction and prosthetic valve or root replacement, are required.

The main difference between PVE in Perceval valves (a sutureless valve) and other types of prosthetic valve infections is the potential to preserve native tissue. Infection in sutureless valves tends to involve a larger area, leading to greater valve annulus destruction, which necessitates a change from prosthetic valve replacement to root replacement surgery. This can complicate procedures like Bentall surgery. Therefore, preoperative evaluation of the presence and extent of aortic valve annular abscesses is crucial, as this may significantly affect surgical planning.

In this case, the intraoperative findings of the removed Perceval valve showed thrombus attached to the NCC and LCC, and a vegetation was observed on the left ventricular side of the RCC. These thrombi and vegetations were cultured, and like preoperative blood cultures, they tested positive for MRSA. Additionally, an abscess was found at the LCC annulus [Fig. 5(a)(b)]. When observed from the left ventricular side, pannus formation was seen at the stent frame's cut edge, rather than at the base of the valve leaflets [Fig. 5(c)]. The pannus formation may be due to turbulence generated between the LVOT and the stent frame, a known characteristic of sutureless valves [11], but more cases are needed to confirm this relationship. Preoperative CT imaging also indicated some pannus protrusion into the LVOT [Fig. 2(c)].

The removed Perceval valve. The removed Perceval valve (a) showed annular destruction on the LCC side due to infection (b) (yellow arrow: entrance of the annular abscess), and pannus formation was observed at the valve's end on the left ventricular side (c) (red arrow: pannus)

We encountered a case of IE and an annular abscess involving an implanted Perceval valve. In cases of infection involving a Perceval valve, the potential spread of infection from the valve annulus to the LVOT is a major concern. The valve was successfully explanted and the aortic root was reconstructed with Bentall surgery. In instances of IE with sutureless valves, preoperative assessment of the presence and extent of annular abscesses is essential. Based on the findings, preoperative management may need to be significantly adjusted to optimize surgical outcomes.

No datasets were generated or analysed during the current study.

Infective endocarditis

Aortic stenosis

Methicillin-resistant Staphylococcus aureus

Aortic regurgitation

Left coronary cusp

Non-coronary cusp

Computed Tomography

Left ventricular outflow tract

Right coronary cusp

Postoperative day

Prosthetic valve endocarditis

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Department of Cardiovascular Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan

Ryo Fujimoto, Shingo Hirao & Tatsuhiko Komiya

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RYO FUJIMOTO and Shingo Hirao drafted the manuscript. Tatsuhiko Komiya supported creating a discussion. All authors read and approved the final manuscript.

Correspondence to Ryo Fujimoto.

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Presentation information: The 13th Annual Meeting of the Japanese Society for Heart Valve Disease, 2023.

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Fujimoto, R., Hirao, S. & Komiya, T. Infective endocarditis with perivalvular abscess following sutureless valve implantation, successfully treated with aortic root reconstruction and biological Bentall procedure. J Cardiothorac Surg 20, 279 (2025). https://doi.org/10.1186/s13019-025-03520-9

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Received: 10 March 2025

Accepted: 19 June 2025

Published: 30 June 2025

DOI: https://doi.org/10.1186/s13019-025-03520-9

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