Ann Thorac Surg 2001;72:255-257
© 2001 The Society of Thoracic Surgeons
Case report
Partial mitral valve replacement for acute endocarditis
J. Mark Jones, AFRCS(Ed)a,
Mazin A.I. Sarsam, FRCS(CTh)a
a Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, Ireland
Accepted for publication June 3, 2000.
Address reprint requests to Dr Jones, Department of Cardiac Surgery, Royal Victoria Hospital, Grosvenor Rd, Belfast BT12 6BA, Northern Ireland
e-mail: mark{at}jmarkjones.freeserve.co.uk
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Abstract
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We present a case of acute endocarditis involving the posteromedial commissure and both leaflets of the mitral valve, including a vegetation on and perforation of the anterior leaflet, in a young man with active Crohn’s disease. Repair was performed using glutaraldehyde-treated bovine pericardium. Competence of the valve was achieved with no recurrence of endocarditis. This case demonstrates that extensive destruction of both leaflets of the mitral valve does not prohibit repair.
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Introduction
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Mitral valve repair has gained increasing acceptance as the procedure of choice for mitral regurgitation [1]. It is also established as a treatment of acute infective endocarditis in the presence of abscess formation, septic emboli, conduction disturbance, or hemodynamic compromise despite antibiotic therapy [2, 3]. However, repair has not been described in the presence of extensive infection involving both leaflets of the mitral valve. We present a case of successful repair of the mitral valve in this situation.
A 28-year-old man with active Crohn’s disease was seen with a 2-week history of pyrexia, hemoptysis, pleuritic chest pain, and dyspnea. He had a systolic murmur and leukocytosis of 23 x 109/L. Colectomy and ileostomy had been performed 7 years previously with subsequent reversal by ileorectal anastomosis 4 years later. He currently had multiple perianal fistulas. Six months earlier, he had had a dental abscess drained. Blood cultures did not identify any organisms. Transesophageal echocardiography demonstrated good left ventricular function, mitral regurgitation, anterior leaflet prolapse, and a vegetation (Fig 1).
Urgent surgical intervention was advocated. Standard cardiopulmonary bypass was established, and a Cosgrove mitral valve retractor (Kapp Surgical Instrument Inc, Cleveland, OH) was used to aid access to the mitral valve through the small left atrium. Endocarditis affected 50% of the anterior leaflet with a vegetation and a perforation and 20% of the posterior leaflet including the posteromedial commissure. The damaged area of the valve was excised, and its dimensions were measured on paper. The chordal attachment was left undisturbed on a strip of leaflet tissue. A piece of bovine pericardium (Supple Periguard, Bio-Vascular Inc, St. Paul, MN) was cut to simulate the excised valve segment and was sutured in place using continuous 5-0 Prolene (Ethicon, Edinburgh, Scotland). The suturing commenced with the leaflet attachment to the annulus, followed by the leaflet attachment to the remainder of both the anterior and posterior leaflets, and ending with the chordal attachment. The posteromedial commissure was narrowed using interrupted 5-0 Prolene to minimize any prolapse (Fig 2). Intraoperative transesophageal echocardiography showed minimal regurgitation of the newly fashioned mitral valve.
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Fig 2. Patch that replaced 50% of anterior leaflet and 20% of posterior leaflet of the mitral valve incorporating the chordal attachment. Interrupted sutures at posteromedial commissure.
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The patient made an uneventful immediate postoperative recovery. Cultures of coagulase-negative Staphylococcus aureus and Enterococcus faecalis were grown from the valve. He received 6 weeks of parenteral antibiotic therapy prior to hospital discharge.
Postoperative echocardiography demonstrated a competent mitral valve with no recurrence of endocarditis (Fig 3). On review at 9 months, the patient was in New York Heart Association functional class I.
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Comment
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Similar functional outcomes have been reported in patients who have had repair or replacement for mitral regurgitation with no episodes of endocarditis in the repair group [1]. Repair for acute endocarditis of the mitral valve has been described previously, but in contrast to our patient, none of the 6 patients from the Cleveland Clinic [2] and none of the 35 from Broussais Hospital [3] had endocarditis involving both leaflets apart from those with ruptured commissural chordae. In no instance were patches applied to both leaflets. A case of endocarditis has been described in which resection of a prolapsing segment of the posterior leaflet was used as an autograft to reconstruct a perforated anterior leaflet [4]. However, unlike the case we have described, the infective process did not extend to both leaflets.
Valve replacement would have been a reasonable approach because of the extensive nature of the disease in this patient. However, repair was considered because of his young age and the presence of active Crohn’s disease with the associated concern about the high risk of reinfection of a prosthetic valve. After radical excision of all infected tissue, repair was undertaken. Although others [3] have found autologous pericardium to be a satisfactory material for mitral valve repair, the high failure rate occurring with use of this material as an autologous pericardial aortic valve both in our experience (unpublished observations) and in published series [5] discouraged us from using it as a patch for extensive repair of the mitral valve. Glutaraldehyde-treated bovine pericardium was used to fashion a patch for the affected areas of the anterior and posterior leaflets. The repair was assessed while the patient was on the operating table and postoperatively with good results. We were keen to minimize insertion of foreign material, and as the repair was satisfactory, there was no indication to perform an additional annuloplasty either with a prosthetic ring or with pericardium [6].
The principle for surgical treatment of endocarditis is excision of all necrotic and infected tissue. Assessment should then be made regarding repair. We have shown that despite active destruction of major segments of both leaflets, repair can be achieved with excellent short-term results in terms of functional status and freedom from endocarditis in a patient at risk for recurrent endocarditis.
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References
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Sand M.E., Naftel D.C., Blackstone E.H., Kirklin J.W., Karp R.B. A comparison of repair and replacement for mitral valve incompetence. J Thorac Cardiovasc Surg 1987;94:208-219.[Abstract]
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Hendren W.G., Morris A.S., Rosenkranz E.R., et al. Mitral valve repair for bacterial endocarditis. J Thorac Cardiovasc Surg 1992;103:124-129.[Abstract]
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Dreyfus G., Serraf A., Jebara V.A., et al. Valve repair in acute endocarditis. Ann Thorac Surg 1990;49:706-713.[Abstract]
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Penta de Peppo A., Zeitani J., De Paulis R., Chiariello L. Autograft from quadrangular resection for floppy valve repair in endocarditis. Ann Thorac Surg 1998;66:270-271.[Abstract/Free Full Text]
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Gross C., Simon P., Grabenwoger M., et al. Midterm results after aortic valve replacement with the autologous tissue cardiac valve. Eur J Cardio-thorac Surg 1999;16:533-539.[Abstract/Free Full Text]
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Abstract
Introduction
