We present a case of a 46-year-old man with a bicuspid aortic valve and anuloaortic ectasia who initially underwent Bentall surgery. The operation and the early postoperative course were uneventful. On the seventh postoperative day, the patient was discharged from hospital. On the 15th postoperative day, on a routine control, signs of inflammation were noted in the sternal wound area, and the patient was treated with antibiotics, according to the antibiogram, on an outpatient basis. One month after the initial surgery there were no signs of inflammation on the sternal wound and the sternum was stable. The first postoperative Transthoracic Echocardiography (TTE) showed normal hemodynamic parameters over the implanted artificial valve.

Sixteen months after the initial operation, the patient complains of general weakness, elevated body temperature and fever, as well as swelling of the hands. Anemia with elevated values of inflammatory markers were recorded in the laboratory findings.

The patient was hospitalized at the Department of Cardiology. Furthermore, blood cultures were taken. And were positive for Staphylococcus warneri. Antibiotic therapy was started. The TTE findings showed perianular endocarditic collections and extremely turbulent blood flow at the level of the left ventricular outflow tract (LVOT) and around the aortic mechanical valve prosthesis. Transesophageal Echocardiography (TEE) showed dehiscence of the composit graft stent on the part of the anulus in the projection of the non-coronary sinus, with a large abscess cavity around the right coronary artery (RCA) ostium and a reoperation was indicated.

The operative procedure was performed under general anesthesia, and heart was arrested using 2000 mL of del Nido cardioplegic solution which was applied anterogradely ostially. Intraoperatively, complete destruction of the aortic anulus and composite graft dehiscence with an abscess cavity in the projection of the non-coronary sinus was noted. The ostia of the coronary arteries and the distal attachment of the conduit to the aorta were intact. The conduit was completely resected. The LVOT, aortic valve anulus, and the abscess cavity are cleaned. Left coronary artery (LCA) button was encircled with dense adhesions and therefore no significant dissection or mobilization of the ostium was possible. A conduit with a mechanical valve (St Jude aortic mech. valved graft No. 25) was implanted. The ostium of the LCA was reimplanted using the great saphenous vein graft interpositum. Cardiopulmonary bypass time was 386 minutes and cardioplegic arrest time was 256 minutes. The heart started spontaneously after warm blood reperfusion. During the operation, there were no significant disorders of acid-base status, electrolyte imbalance, arterial blood pressure, or other laboratory findings. The early postoperative course was uneventful. Postoperatively, the patient was treated with the antibiotic therapy that consisted of rifampicin, meropenem, and vancomycin. Postoperative blood cultures were sterile. At discharge, the sternum was stable, and the wound was healing properly. Postoperative TTE on the third postoperative day showed normal hemodynamic parameters over the implanted aortic valve prosthesis The patient was discharged home on the eighth postoperative day. Control TTE 15 days and two months after surgery showed normal hemodynamic parameters over the artificial valve with normal segmental and global contractility of the left ventricle, and left ventricular ejection fraction was (LVEF) 65%.