HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael W. Frank Constantine Mavroudis Carl L. Backer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Frank, M. W. Articles by Rocchini, A. P. Search for Related Content PubMed PubMed Citation Articles by Frank, M. W. Articles by Rocchini, A. P.

Ann Thorac Surg 1998;65:1788-1790
© 1998 The Society of Thoracic Surgeons

---

Case Reports

Repair of Mitral Valve and Subaortic Mycotic Aneurysm in a Child With Endocarditis

^a Divisions of Cardiovascular-Thoracic Surgery and Cardiology, Children’s Memorial Hospital, and Departments of Surgery and Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA

Accepted for publication January 12, 1998.

Address reprint requests to Dr Mavroudis, Division of Cardiovascular-Thoracic Surgery, M/C #22, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614
e-mail: (c-mavroudis{at}nwu.edu)

	Abstract

Top Abstract Introduction Comment References

 
Endocarditis requiring surgical intervention in children is uncommon. Individualized operative therapy must be fashioned to the particular pathology of each case. In this case we describe mitral anterior leaflet homograft patch augmentation valvuloplasty, subaortic homograft patch closure of a large mycotic aneurysm, and homograft aortic root replacement in a 3-year-old patient with endocarditis after remote repair of complete atrioventricular canal.

	Introduction

Top Abstract Introduction Comment References

 
Endocarditis requiring surgical intervention is uncommon, particularly in younger children [1, 2]. Individualized surgical therapy must be fashioned to address the particular pathology in each case [3]. Often, this will require reconstructive techniques to restore valve function, preserve the cavitary integrity of the heart, and avoid prosthetic materials. In this case report we describe an interesting case of endocarditis after remote repair of complete atrioventricular canal involving the aortic valve, the mitral valve, and a subaortic erosion resulting in an extracardiac mycotic aneurysm. One aortic homograft provided enough homograft tissue to effectively treat all lesions.

A 3-year-old girl with Down syndrome had previous repair (6 months of age) of complete atrioventricular canal using the one-patch technique at another institution. A small accessory leaflet involving the posterior common leaflet was excised and the "cleft" was closed. A subsequent transesophageal echocardiogram revealed mild mitral regurgitation.

When the patient was 2 years of age, left ventricular outflow tract obstruction and moderate mitral regurgitation developed. Evaluation revealed that the anterior leaflet of the mitral valve was tethered by accessory mitral tissue. At the second operation, accessory mitral tissue was resected, a hole in the anterior leaflet was primarily repaired, and left ventricular muscle was resected to open the aortic outflow tract. Postoperatively, mitral regurgitation was mild and the left ventricular outflow tract gradient significantly decreased.

One year later severe aortic regurgitation, severe mitral regurgitation with ongoing sepsis, and endocarditis developed. Blood cultures were positive for Streptococcus pneumoniae. The patient was treated with intravenous antibiotics and inotropic support without improvement for 15 weeks. She subsequently was transferred to our institution. The preoperative echocardiogram revealed moderate left atrial dilatation, severe left ventricular dilatation, severe mitral regurgitation (posterior and laterally directed regurgitant jet), subaortic outflow tract narrowing (peak gradient of 25 mm Hg), severe aortic insufficiency, and an extracardiac mycotic aneurysm (Fig 1) arising from the subaortic area.

View larger version (119K): [in this window] [in a new window]   Fig 1. Preoperative magnetic resonance image of the left ventricular outflow tract demonstrating the subaortic mycotic false aneurysm (arrow) between the left ventricular outflow tract and the pulmonary artery. The dark central stream in the left ventricular outflow tract represents the aortic insufficiency jet.

A fibromuscular resection eliminated the subaortic obstruction. The subaortic annular abscess was debrided. Using a modification of techniques described by David and colleagues [4], we closed the orifice to the mycotic aneurysm with an aortic homograft patch, thereby excluding the aneurysm from the left ventricular outflow tract (Fig 2). The mitral valve was repaired with modified Carpentier techniques [5]. An incision was made in the base of the anterior leaflet of the mitral valve parallel to the arc of the anulus. Several secondary chordal attachments were resected. The anterior leaflet of the homograft mitral valve that was included with the aortic root was cut to size and sewn to the gap developed by the incision in the base of the anterior leaflet of the patient’s mitral valve. This effectively augmented the size of the anterior mitral leaflet and advanced the leading edge of the anterior leaflet and allowed proper coaptation with the posterior leaflet (see Fig 2).

View larger version (115K): [in this window] [in a new window]   Fig 2. Operative repair using the various components of the aortic homograft: (A) homograft anterior mitral valve tissue used for mitral valve repair, (B) homograft aortic root used for aortic root replacement, and (C) homograft patch used to close the mycotic aneurysm.

The patient was separated from cardiopulmonary bypass without difficulty. An intraoperative transesophageal echocardiogram and postoperative transthoracic echocardiogram showed mild mitral regurgitation, no aortic homograft insufficiency, no aortic stenosis, no subvalvar or supravalvar narrowing, and no vascular communication to the area of the obliterated false aneurysm. After a smooth postoperative course, the patient was discharged. She has completed a 6-week course of intravenous antibiotics and has not had recurrent endocarditis.

	Comment

Top Abstract Introduction Comment References

 
Surgical intervention for endocarditis in children requires individualized therapy. The goals are to eradicate infection, restore function, and avoid prosthetic material. In this case report an insufficient aortic valve, an insufficient mitral valve, and a subaortic mycotic aneurysm were repaired with tissue from a single cryopreserved aortic homograft.

We deviated from our preoperative plan to perform a Ross procedure because of the mycotic aneurysm’s size, location, and proximity to the left main coronary artery. Homograft aortic root replacement was preferable to prosthetic valve replacement and Konno procedure because prosthetic material could be avoided. Dearani and associates’ [6] series from the Mayo Clinic has reported (in adults) that the risk of reoperation at 5 years after allograft aortic valve replacement for complex endocarditis (36 patients) was 8% ± 5.6%, with no recurrence of endocarditis. The described mitral valve repair is rare. It is useful in patients who are lacking sufficient anterior leaflet tissue (Zias EA, Mavroudis C, Backer CL, Kohr LM, Gotteiner NL, Rocchini AP; unpublished results). Mitral regurgitation in our patient may have been caused by a congenital malformation, prior resection, or endocarditis. Repair using this technique avoids mitral valve replacement in young children and the very significant associated morbidity and mortality [7]. The outcome of homograft tissue in the mitral valve will be carefully monitored over time. Dearani and colleagues reported a variation of this technique, keeping the mitral leaflet attached to the aortic homograft and using it successfully as part of the repair of the mitral valve in 6 patients.

Most interesting is the large size and position of the subaortic mycotic aneurysm that tunneled outside the confines of the subaortic left ventricular outflow tract and was bounded by the ascending aorta, the main pulmonary artery, and the left main coronary artery. Subaortic mycotic aneurysms in this position are extremely rare, particularly in the absence of prosthetic valve endocarditis. What part the second operation (in which a subaortic muscle resection was performed) played in the development of this aneurysm is speculative. Homograft patch closure of the orifice of the aneurysm effectively excluded and obliterated the aneurysm. Because the coronary arteries and pulmonary artery constituted the external wall of the aneurysm, it was not possible to excise the aneurysm. Of course, it is certain that our patient will require reoperation for aortic homograft failure and possible mitral valve re-repair or replacement in the future. The present operation allows for resolution of congestive heart failure, obliteration of the aneurysm, and sterilization of the infectious process. This should optimize the options and success rate for the next operation.

In summary, individualized surgical therapy is often necessary to address the complicated pathology found in these uncommon cases.

	References

Top Abstract Introduction Comment References

 

1. Citak M., Rees A., Mavroudis C. Surgical management of infective endocarditis in children. Ann Thorac Surg 1992;54:755-760.[Abstract]
2. Tolan R.W., Kleiman M.B., Frank M., King H., Brown J.W. Operative intervention in active endocarditis in children: report of a series of cases and review. Clin Inf Dis 1992;14:852-862.[Medline]
3. Mavroudis C., Wampler J., Hodsden J.E., Rees A.H., Solinger R.E., Elbl F. Modified aortoseptoplasty for annular abscess and erosion of the membranous septum. Chest 1984;85:442-444.[Abstract/Free Full Text]
4. David T.E., Komeda M., Brofman P.R. Surgical treatment of aortic root abscess. Circulation 1989;80(Suppl 1):269-274.
5. Chauvaud S., Jebara V., Chachques J.C., et al. Valve extension with glutaraldehyde-preserved autologous pericardium. Results in mitral valve repair. J Thorac Cardiovasc Surg 1991;102:171-178.[Abstract]
6. Dearani J.A., Orszulak T.A., Schaff H.V., Daly R.C., Anderson B.J., Danielson G.K. Results of allograft aortic valve replacement for complex endocarditis. J Thorac Cardiovasc Surg 1997;113:285-291.[Abstract/Free Full Text]
7. Kadoba K., Jonas R.A., Mayer J.E., Castañeda A.R. Mitral valve replacement in the first year of life. J Thorac Cardiovasc Surg 1990;100:762-768.[Abstract]

This article has been cited by other articles:

				D. G. Healy and A. E. Wood Anterior Mitral Leaflet Reconstruction With Pericardium in a 1.9 kg Infant With Endocarditis Ann. Thorac. Surg., June 1, 2006; 81(6): 2310 - 2312. [Abstract] [Full Text] [PDF]

				E. A. Zias, C. Mavroudis, C. L. Backer, L. M. Kohr, N. L. Gotteiner, and A. P. Rocchini Surgical repair of the congenitally malformed mitral valve in infants and children Ann. Thorac. Surg., November 1, 1998; 66(5): 1551 - 1559. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael W. Frank Constantine Mavroudis Carl L. Backer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Frank, M. W. Articles by Rocchini, A. P. Search for Related Content PubMed PubMed Citation Articles by Frank, M. W. Articles by Rocchini, A. P.