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Ann Thorac Surg 1998;66:267-268
© 1998 The Society of Thoracic Surgeons

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Case Reports

Combined mitral and aortic homograft valve replacement for acute bacterial endocarditis

^a Department of Surgery, Deaconess Medical Center, Spokane, Washington, USA

Accepted for publication February 9, 1998.

Address reprint requests to Dr Amado-Cattaneo, Cardiovascular & Thoracic Surgical Associates, PS, 122 W Seventh Ave, Suite 440, Spokane, WA 99204

	Abstract

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Homograft replacement of the aortic valve in cases of acute bacterial endocarditis is considered the ideal choice because of the resistance of the homograft to reinfection. We report a case of aortic and mitral valve bacterial endocarditis, secondary to Streptococcus viridans, with severe aortic and mitral valve regurgitation and hemodynamic instability requiring surgical interventions with the use of aortic and mitral valve homografts.

	Introduction

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The patient is a 39-year-old man who was in his usual state of good health until approximately 4 weeks before admission to the hospital. At that time, he states that a cough developed that was productive of thick yellow sputum. His illness progressed, developing a sore throat, difficulty swallowing, anorexia, nausea, and vomiting. Myalgia and arthalgia also developed. At this point, he sought medical attention. He was admitted to the hospital with a temperature of 38.9°C, pulse rate of 122/min, and tachypnea. Room air saturations were 93% to 98%. Blood cultures were obtained, and these were positive for Streptococcus viridans. He was begun on intravenous antibiotics. The patient had a previous history of intravenous drug abuse. He denied any previous history of endocarditis or any other febrile illnesses.

Cardiac examination revealed loud systolic and diastolic murmurs, sinus tachycardia, and rales bilaterally. Transesophageal echocardiography revealed severe aortic and mitral valve regurgitation with massive vegetations noted in the aortic valve and underneath the mitral valve. There was moderate dilatation of the left ventricle. The patient became progressively more dyspneic. Coronary arteriograms revealed normal coronary arteries.

The patient was taken to operation. Double cannulation of the superior and inferior vena cavas was performed. A single cannula was inserted in the distal ascending aorta. A transseptal approach to the mitral valve was accomplished. Retrograde cardioplegia was infused in the coronary sinus throughout the procedure. The aortic valve was totally destroyed, with an immense amount of vegetation involving the remnants of the leaflets of the aortic annulus. The vegetations extended down into the anterior leaflet and the mitral valve, with involvement of the anterior papillary muscle subvalvular apparatus and perforation of the anterior leaflet of the mitral valve. The pulmonary and tricuspid valves were free of vegetations.

The decision was made to replace the aortic valve and mitral valve with a Cryolife (Kennesaw, GA) aortic and mitral homograft. A 23-mm miniroot aortic valve homograft was selected for the aortic valve replacement and a 33-mm mitral valve homograft for the mitral valve replacement. Sizing of the mitral valve was accomplished preoperatively by transesophageal echocardiography, measuring the height of the anterior leaflet of the mitral valve from the annulus to the free edge of the anterior leaflet, as described by Acar and associates [1]. This distance was 33 mm. Intraoperative measurement of the mitral valve anterior leaflet corresponded exactly to the transesophageal echocardiographic measurement of the height of the anterior leaflet of the mitral valve.

While the aortic and mitral valve homograft were being thawed, attention was given first to excising the aortic valve and preparing the left and right coronary ostia for reimplantation. The mitral valve was excised next in preparation for the replacement. The aortic valve miniroot was done first. Interrupted 3-0 Ticron (Sherwood Davis & Geck, St. Louis, MO) sutures were used to suture the miniroot to the annulus of the aortic valve. The miniroot was placed in its anatomic position. The left coronary ostium was reimplanted next with a running 6-0 Prolene (Ethicon, Somerville, NJ) suture. The distal aortic anastomosis was then constructed with a running 4-0 Prolene suture. Finally, the right coronary ostium was reimplanted with a running 6-0 Prolene suture. Attention was given next to replacing the mitral valve. The excess atrial and ventricular muscle was trimmed off the annulus of the mitral valve homograft using Acar and associates’ [2] technique. The papillary muscles were thereafter trimmed to a length of 1 cm from the tip of the papillary muscles. The anatomy of the mitral valve homograft showed the posterior papillary muscle to be a type I, that is, one single head, and the anterior papillary was a type II, that is, two separate heads. The posterior papillary muscle was sutured first, side-to-side to the recipient papillary muscle, in between the papillary muscle and the ventricular wall. Peters Laboratory 5-0 Cardionyl (Vista Cardiothoracic Surgery, Westborough, MA) suture was used for this anastomosis. Two stitches were placed at the base to secure the papillary muscle in place, and thereafter a total of ten interrupted stitches were placed to accomplish secure side-to-side attachment of the recipient and donor papillary muscles. Next, the anterior papillary muscle was anastomosed to the anterior papillary muscle of the recipient. A similar technique was used with placement of the donor papillary muscle in between the recipient papillary muscle and the wall of the ventricle. A total of twelve 5-0 Cardionyl interrupted stitches were used to secure this muscle. Care was taken in placing the papillary muscles slightly below the level of the tip of the recipient papillary muscles. The next step was the placement of interrupted 2-0 Ticron stitches for the placement of the Carpentier-Edwards ring. These stitches were placed in a U fashion and were left lying on the field after all the sutures were in place. The annulus of the mitral valve homograft was sewn to the annulus of the recipient with a running 4-0 Cardionyl suture. Care was taken in aligning the trigone of the homograft with the trigone of the recipient annulus. The running suture was begun at the level of the posterior commissure in a counterclockwise manner all around, in this manner allowing the tissue of the mitral valve to overlie the annulus of the recipient mitral valve. A Carpentier-Edwards (Baxter Edwards, Cardiovascular Surgery Division, Irvine, CA) 32-mm ring was then brought to the field and the sutures were placed through the ring and the ring was tied in place.

Testing of the mitral valve homograft for leakage revealed no leakage. The atriotomy was closed in routine fashion. Total cross-clamping time was 314 minutes and the total bypass time was 359 minutes. The patient went off bypass without any trouble. Postbypass transesophageal echocardiography revealed perfect function of both aortic and mitral homografts with no evidence of leakage.

The patient completed his postoperative recovery without any complications. He was discharged 10 days from the day of his admission to the hospital. Transesophageal echocardiography performed before discharge revealed, again, no evidence of leakage from either the mitral or aortic homograft. The patient was continued on intravenous antibiotics for a total of 6 weeks. Gram stains of the valve tissue were packed with gram-positive cocci in pairs and chains. Final cultures were reported as having "no growth."

Seven months postoperatively, the patient continues to do extremely well with an absolutely normal cardiac examination and is in New York Heart Association class I. There is no evidence of reinfection.

	Comment

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The exact role for homograft mitral valve replacement in the case of acute bacterial endocarditis is unclear at this point [3]. However, it is reasonable to believe that similar good results as with homograft aortic valve replacement for acute bacterial endocarditis will be accomplished once enough experience has been accumulated. Ideally at this time, if at all possible, repair of the mitral valve with or without pericardial patch of the perforations should be tried first. In this case, extensive damage of the anterior leaflet and subvalvular apparutus prevented us from carrying out a repair. Because of the fact that both valves had to be replaced in a young man with a history of drug abuse and knowing that the ideal replacement for acute endocarditis of the aortic valve is a homograft, we decided to use two homografts.

The long cross-clamping time could be considered a drawback, but in a patient with a normal left ventricle, normal coronary arteries, and good retrograde cardioplegia, this was not a problem, and the patient was weaned off bypass without any trouble at all.

	References

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1. Acar C., Tolan M., Berrebi A., et al. Homograft replacement of the mitral valve. J Thorac Cardiovasc Surg 1996;111:367-380.[Abstract/Free Full Text]
2. Acar C., Iung B., Cormier B., et al. Double mitral homograft for recurrent bacterial endocarditis of the mitral and tricuspid valves. J Heart Valve Dis 1994;3:470-472.[Medline]
3. Pomar J., Mestres C. Tricuspid valve replacement using a mitral homograft. Surgical technique and initial results. J Heart Valve Dis 1993;2:125-128.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Roberto Amado-Cattaneo Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Amado-Cattaneo, R. Search for Related Content PubMed PubMed Citation Articles by Amado-Cattaneo, R.