Ann Thorac Surg 1998;66:270-271
© 1998 The Society of Thoracic Surgeons
Case Reports
Autograft from quadrangular resection for floppy valve repair in endocarditis
Alfonso Penta de Peppo, MDa,
Jacob Zeitani, MDa,
Ruggero De Paulis, MDa,
Luigi Chiariello, MDa
a Division of Cardiac Surgery, University of Rome Tor Vergata, European Hospital, Rome, Italy
Accepted for publication February 11, 1998.
Address reprint requests to Dr Penta de Peppo, Divisione di Cardiochirurgia, Universita’ di Roma Tor Vergata, European Hospital, Via Portuense 700, 00149 Rome, Italy
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Abstract
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We present a case of reconstruction of the anterior leaflet in mitral valve prolapse and subacute bacterial endocarditis in which the resected prolapsing segment of the posterior leaflet was used as patch material. Competence of the valve was achieved with no recurrence of infection. Quadrangular resection of the posterior leaflet supplies presumably viable patch material for valve repair, which is particularly useful in bacterial endocarditis and when pliability is required.
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Introduction
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Myxomatous degeneration of the mitral valve predisposes to development of bacterial endocarditis [1]. Septic perforations of the leaflets may be associated with valve prolapse, increasing valve incompetence and often requiring use of a patch for repair. The optimal patch material is not yet fully established, as it should be resistant to persistent or recurrent endocarditis and maintain long-term pliability. We present a technique using the autologous resected segment of the posterior leaflet for patch reconstruction of the region of closure of the perforated anterior leaflet.
A 72-year-old male patient was admitted with a medical history of progressive dyspnea on effort and episodes of paroxysmal nocturnal dyspnea for the last 3 months. Physical examination showed an elderly man in no acute distress and a 4/6 apical systolic murmur. His chest roentgenogram showed cardiomegaly and pulmonary venous congestion. Doppler echocardiography disclosed mitral valve prolapse and severe mitral regurgitation; cardiac catheterization confirmed mitral regurgitation and left ventricular enlargement. The patient was febrile (38°C) the evening of the fifth day after admission; the temperature recurred the following day (37.5°C) and then subsided without treatment. Nine blood cultures were taken and had negative results. The white blood cell count and the erythrocyte sedimentation rate were normal.
The patient underwent surgical repair on the 11th day. Inspection of the valve at operation showed prolapse of the medial segment of the posterior leaflet with elongated and ruptured chordae and an 8-mm perforation with inflammation of the surrounding tissue into the central aspect of a redundant anterior leaflet (Fig 1). All macroscopically inflamed tissue was resected, leaving a narrow strip of the anterior free edge with its supporting chordae and a 1.6-cm-diameter hole, suitable for patch closure. A quadrangular resection of the posterior prolapsing segment was then performed. The resected posterior segment was freed from chordal attachment, trimmed to a 1.7-cm quadrangular shape, and placed over the anterior defect. Patch closure of the hole was accomplished with 5-0 polypropylene running sutures along the four borders of the patch (Fig 2); simultaneous reduction of the redundant anterior leaflet was achieved by suturing with larger bites toward the free edge of the leaflet. The posterior leaflet was then sutured with double 5-0 polypropylene running sutures and the procedure was completed by plication of the posterior annulus and by annuloplasty at each commissure with separate 2-0 Dacron polyester stitches. No prosthetic ring was implanted.
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Fig 1. Operative photograph showing the anterior mitral leaflet (AL) with perforation of the central portion (stretched by a curved forceps) and the posterior leaflet (PL) with the redundant segment and a ruptured chorda.
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Fig 2. Operative photograph showing autograft patch reconstruction of the anterior leaflet (asterisk) after quadrangular resection of the posterior leaflet (arrows). A narrow strip of the free anterior margin with the supporting chordae (exposed by a curved forceps) was preserved.
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Intraoperative transesophageal echocardiography showed minimal residual valve regurgitation. Culture of the resected valve tissue revealed Staphylococcus aureus as the microorganism responsible for the infection, and the patient was placed on a 6-week course of netilmicin and vancomicin therapy. The postoperative course was uneventful and the patient remained afebrile. He was discharged on the 10th postoperative day and anticoagulated with warfarin for 2 months. Color Doppler echocardiography was performed before discharge (Fig 3) and at 1 and 4 postoperative months and showed stable mild mitral valve regurgitation and reduced ventricular dimensions. The white blood cell count, erythrocyte sedimentation rate, and protein C-reactive value were normal. The patient is well and in New York Heart Association class II 7 months after the operation.
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Fig 3. Postoperative transesophageal echocardiogram illustrating the central jet (A, encircled area) of mild regurgitation in the left atrium (LA). The left ventricle (LV) and aorta (AO) with the fully open aortic valve are also shown.
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Comment
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Valve repair in bacterial endocarditis is effective in most patients and appears resistant to recurrent infection compared with valve replacement [2]. Patch reconstruction may, however, be required to repair destroyed valvular tissue that would otherwise need replacement. The efficacy of tanned xenograft pericardium for valve repair is jeopardized by the risk of calcification and tissue failure [3]. Glutaraldehyde-preserved autologous pericardium has been proposed as optimal patch material, being superior to heterologous treated pericardium because of its lack of antigenicity and to fresh autograft pericardium because its risk of shrinkage is prevented by glutaraldehyde fixation [4]. However, thickening of autologous tanned pericardium, which is made of nonviable cells, may be of concern in repair of the region of closure and of the free edge of the leaflets, where long-term pliability is required.
Quadrangular resection of the posterior leaflet supplies pliable and presumably vital autologous biologic tissue, which may not require chemical stabilization, as no abnormal retraction or thickening of this patch material is expected. The prolapsing posterior segment in myxomatous valves is usually large enough for adequate patch reconstruction of the opposite leaflet. Although the vitality of this patch remains theoretical, it is hoped that the expected long-term pliability of the intact autologous tissue will favor durability of repair and resistance to recurrence of endocarditis, as suggested by the uneventful course in our patient 5 months after the discontinuation of antibiotic therapy.
Implanting myxomatous tissue, however, presents some potential limitations. In fact, long-term stability of the autotransplanted tissue needs to be confirmed; moreover, the prolapsing segment of severely myxomatous valves might be badly degenerated and therefore might not be suitable to be used as a patch. Nevertheless, this redundant autologous tissue may prove to be excellent material for patch repair of associated valve lesions, particularly in endocarditis or when pliability is required.
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References
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- Clemens J.D., Horwitz R.I., Jaffe C., Feinstein A.R., Stanton B.F. A controlled evaluation of the risk of bacterial endocarditis in persons with mitral-valve prolapse. N Engl J Med 1982;307:776-781.[Abstract]
- Dreyfus G., Serraf A., Jebara V.A., et al. Valve repair in acute endocarditis. Ann Thorac Surg 1990;49:706-713.[Abstract]
- Trowbridge A., Lawford P., Crofts C., Roberts K. Pericardial heterografts. Why do these valves fail?. J Thorac Cardiovasc Surg 1988;95:577-585.[Abstract]
- 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]
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Abstract
Introduction
