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Ann Thorac Surg 1999;68:1727-1730
© 1999 The Society of Thoracic Surgeons

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Original Articles

Commissuroplasty: a method of valve repair for mitral and tricuspid endocarditis

^a Department of Cardiothoracic Surgery, Westmead Hospital & Royal Alexandra Hospital for Children, Sydney, Australia

Address reprint requests to Dr Chard, Children’s Hospital Medical Centre, Suite 8, Level 1, Hainsworth St, Westmead NSW 2145, Australia
e-mail: chardric{at}netspace.net.au

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. We describe our experience with a technique of cusp commissuroplasty to reconstruct atrioventricular valves damaged by endocarditis of the commissure and adjacent cusps.

Methods. We operated on 3 patients with mitral endocarditis and one patient with previous tricuspid endocarditis. Infected leaflet tissue was excised from each side of the commissure, leaving a defect between one quarter and one third of the valve area. Using the technique of valve commissuroplasty, leaflet remnants were reapposed at the cut edges to obliterate the commissure. The residual D-shaped defect between the apposed leaflets and annulus was either closed directly or patched with pericardium, depending on the size of the defect.

Results. Constructing unicommissural mitral and bicuspid tricuspid valves restored leaflet continuity. One patient was lost to follow-up. Postoperative echocardiography performed at a mean interval of 14.7 months showed competent and nonobstructed valves. There was no recurrent endocarditis at a mean follow-up time of 15.7 months.

Conclusions. The technique of cusp commissuroplasty can be used to reconstruct atrioventricular valves that have been damaged by endocarditis of the commissure and adjacent cusps.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Mitral valve conservation has advantages over mitral valve replacement: left ventricular function is better preserved [1–3], and the prospect of long-term anticoagulation is avoided. Various techniques of mitral valve conservation have been used to treat mitral endocarditis, and the results were good, with low perioperative morbidity and mortality rates and a low incidence of recurrent endocarditis [4–7]. In contrast, there have been only isolated reports of valve conservation with tricuspid endocarditis [8, 9].

The site and size of the valvular defect is critical in determining whether atrioventricular valve repair would be feasible. For abscesses located in the commissures, contiguous tissue loss from two adjacent cusps would produce a valve defect that cannot be repaired with standard techniques. We describe a technique of leaflet commissuroplasty, which was used in adult and adolescent patients to reconstruct atrioventricular valves that were damaged by endocarditis of the commissures.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
A total of 33 patients were referred with mitral (n = 30) or tricuspid (n = 3) endocarditis between February 1995 and June 1998. Of the 30 patients with mitral endocarditis, 27 had mitral valve replacement, and in 3 the mitral valve was conserved by using the technique of cusp commissuroplasty. Of the 3 patients with tricuspid endocarditis, two had tricuspid valve replacement for active endocarditis and one had cusp commissuroplasty to conserve a valve with healed endocarditis.

The median age of patients (n = 3) who had cusp commissuroplasty was 14.6 years (range, 12 to 19 years) and the mean weight was 49 kg (range, 40 to 67 kg). The mitral regurgitation was mild to moderate without hemodynamic compromise. Blood cultures yielded growth of Staphylococcus aureus. Echocardiography demonstrated vegetations either in the anterolateral (n = 1) or posteromedial commissures (n = 2). An operation was indicated because of uncontrolled sepsis. Flucloxacillin was administered intravenously for 6 weeks.

The patient with healed tricuspid endocarditis was 39 years old. Twenty years earlier he had endocarditis associated with a small perimembranous ventricular septal defect, and he had an operation in which the infected septal leaflet and one third of the anterior leaflet were excised and the ventricular septal defect was patched with pericardium. The substantial defect in the tricuspid valve resulted in severe tricuspid incompetence leading to atrial enlargement, atrial fibrillation, and recurrent pulmonary emboli. An operation was indicated to improve right heart failure and restore sinus rhythm.

Surgical technique
A median sternotomy was done. Cardiopulmonary bypass was established with aortobicaval cannulation, and moderate hypothermia was attained by core cooling to 32°C. A superior transseptal atrial incision was used to approach an abscess of the posteromedial commissure in 2 patients (Fig 1A), a longitudinal left atriotomy was used to expose an abscess of the anterolateral commissure in 1 patient.

View larger version (27K): [in this window] [in a new window]   Fig 1. (A) Vegetation and abscess located in the posteromedial commissure of the mitral valve. (B) Radical debridement of the infected annulus and adjacent leaflets resulted in a large defect in the mitral valve orifice. The annular defect was patched with pericardium. (C) The leaflet remnants were approximated at the leading edge with a horizontal mattress suture to form a zone of apposition (inset). The residual D-shaped defect between the mitral annular patch and apposed leaflets was closed with a pericardial patch, thus restoring valve competence.

The debrided mitral annulus was reconstructed according to the technique of David and colleagues [10]. A piece of pericardium was tanned for 10 minutes with 0.6% glutaraldehyde solution [11] and tailored to a size slightly greater than the area of the unroofed abscess [10]. The slight redundant amount of pericardium allowed sufficient laxity for the patch to be molded to the shape of the left ventricular cavity. The patch was sutured to the endocardium along the rim of the defect, using continuous 5-0 polypropylene suture (Fig 1B). The patch was oriented so that the visceral side faced the ventricular cavity.

The leaflet remnants had normal morphologic characteristics. The disrupted commissure was reconstructed by approximating cusp remnants at the level of their normal closure, forming a zone of apposition by using a single horizontal mattress stitch with 4-0 polypropylene suture and pericardial pledgets. Leaflet apposition resulted in a D-shaped defect between the apposed leaflets and annular patch. If the leaflet loss was relatively small, the D-shaped defect could be closed directly by suturing the apposed leaflets to the annular patch. This technique was used in 1 patient with leaflet losses equivalent to one quarter of the mitral valve area. For substantial leaflet loss, the larger D-shaped defect was closed with autologous pericardium, which was tanned and sutured in place with 5-0 polypropylene with the visceral side facing the ventricle (Fig 1C). This technique was used in 2 patients with leaflet losses equivalent to one third of the mitral valve area. The mitral valves were reconstructed to function as unicommissural bicuspid valves, and annuloplasty rings were not used.

The incompetent tricuspid valve (Fig 2A) was reconstructed using a similar technique. To treat chronic atrial fibrillation, a maze-type procedure was done during the same operation by using a hand-held radiofrequency probe to create linear endocardial radiofrequency lesions instead of incising the atrium. The remaining two thirds of the anterior cusp and intact inferior cusp were approximated along a zone of apposition (Fig 2B). The substantial D-shaped defect between the apposed leaflets and tricuspid annulus was patched with autologous pericardium (Fig 2B). A 29-mm Duran annuloplasty ring was inserted because of marked dilatation of the annulus (Fig 2C). The tricuspid valve was reconstructed to function as a unicommissural bicuspid valve.

View larger version (24K): [in this window] [in a new window]   Fig 2. (A) Incompetent and dilated tricuspid valve after excision of the septal leaflet and one third of the anterior leaflet. The ventricular septal defect was patched with pericardium. (B) The inferior leaflet and remnant of the anterior leaflet were approximated with a horizontal mattress suture to form a zone of apposition (inset). The residual D-shaped defect between the dilated tricuspid annulus and apposed leaflets was patched with pericardium to produce a competent valve. (C) An annuloplasty ring was inserted to reduce the size of the tricuspid annulus.

	Results

Top Abstract Introduction Patients and methods Results Comment References

There were no operative deaths. All patients recovered without incident and were discharged in sinus rhythm. One patient who had mitral valve repair was lost to follow-up. Postoperative echocardiography in the remaining 3 patients at a mean interval of 14.7 months (range, 3 to 30 months) showed competent atrioventricular valves and no gradients across the reduced valve area. The patients were free from recurrent endocarditis at a mean follow-up of 15.7 months (range, 6 to 30 months). The patient who had the maze-type procedure remained in sinus rhythm at 11 months postoperatively.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
There have been only a few reports of successful mitral valve conservation for endocarditis of the mitral annulus [6, 7]. The damaged annulus can be reconstructed with either autologous or bovine pericardium. However, significant leaflet losses are usual and have often deemed mitral valve replacement necessary [10]. For annular abscesses with limited leaflet losses, the mitral valve can be conserved by annular plication and patching [6, 7, 10].

Endocarditis associated with the commissures creates the problem of contiguous tissue loss from two adjacent cusps and the annulus. This valve lesion cannot be repaired by standard techniques [7, 10, 11] but can be reconstructed by using our technique of cusp commissuroplasty. The disrupted commissure is obliterated by approximating leaflet remnants at the level of their normal closure along a zone of apposition. The resulting D-shaped defect between the apposed leaflets and annulus is either closed directly or patched, depending on the size of the defect. The reduced valve area and diminished leaflet mobility from commissuroplasty might obstruct the valve; however, there is considerable redundant mitral and tricuspid valve area, which can be sacrificed without detriment. It is apparent in pediatric patients that atrioventricular valves can be made considerably smaller than the native-sized valve for a normal heart [12].

The extent to which the valve can be made smaller without adverse effects can be inferred from the excellent prognosis of patients with mild rheumatic mitral stenosis. Few hemodynamic or clinical abnormalities were noted until the mitral valve area was reduced from its normal value of 4 to 6 cm² to less than 2 cm². One can therefore presume that at least one third of the valve area can be sacrificed without detriment. In our series of mitral valves, at least one third of the anterior leaflet and posterior leaflet area was removed and patched with no gradient across the valve. For the tricuspid valve, the entire septal leaflet and one third of the anterior leaflet was removed and patched without hemodynamic compromise.

Commissuroplasty retains only native subvalvar support structures and native leaflets with the anticipated life-long durability of these structures as opposed to the risk of mechanical failure when using pericardium, polytetrafluoroethylene, or other material as valve substitutes [11]. Pericardium used as an immobile patch in commissuroplasty might be subjected to less stress than pericardium used as leaflet substitute and therefore might be less prone to tissue failure. Although we treated pericardium with glutaraldehyde solution to prevent future calcification and tissue failure [11], the commissuroplasty repair would not be compromised by patch shrinkage. We did not do a conventional mitral annuloplasty, which is indicated for repair of valves with reduced leaflet area. We believed that the suturing of cusp remnants to the annular pericardial patch mimicked a segmental annuloplasty. Pericardial tissue was sufficiently durable to afford reliable mitral annuloplasties [13].

The medium-term results of mitral valve conservation for endocarditis have been good, with a low incidence of recurrent endocarditis [4–7]. The mean follow-up time of 15.7 months in the present series was sufficiently long to qualify the risk of recurrent endocarditis as being minimal after cusp commissuroplasty of infected atrioventricular valves. The mean follow-up time of 14.7 months with echocardiography was relatively short to assess the long-term adequacy of cusp commissuroplasty. However, the cusp remnants were morphologically normal to begin with, and the surgical repair should prove durable provided that there is no recurrence of endocarditis. Although mitral valve replacement with subvalvar preservation would be technically less complex and maintain left ventricular function to an equivalent extent as mitral valve commissuroplasty, we prefer to conserve the native valves in our young patients to avoid long-term anticoagulation.

The standard techniques for valve conservation have been used largely for patients with limited endocarditis. The standard methods include shaving of vegetations, patch repair of leaflet perforations, chordal transposition or replacement, quadrangular resection and leafletoplasty, and valve extension with pericardium to restore leaflet continuity [7]. These traditional methods would not be effective in dealing with commissural abscesses and contiguous leaflet losses from each side of the commissure.

We recommend that commissuroplasty be considered as an option for valve conservation when one must treat an extensive abscess involving the commissural annulus and adjacent cusps of atrioventricular valves.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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9. Yee E.S., Ullyot D.J. Reparative approach for right-sided endocarditis. Operative considerations and results of valvuloplasty. J Thorac Cardiovasc Surg 1988;96:133-140.[Abstract]
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