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Ann Thorac Surg 2007;84:2059-2065. doi:10.1016/j.athoracsur.2007.07.038
© 2007 The Society of Thoracic Surgeons
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Original Articles: Cardiovascular

Mitral Valve Repair for Infective Endocarditis in Children

Eva Maria Delmo Walter, MDa,*, Michele Musci, MDa, Nicole Nagdyman, MDb, Michael Hübler, MDa, Felix Berger, MD, PhDb, Roland Hetzer, MD, PhDa

a Department of Cardiovascular and Thoracic Surgery, German Heart Center of Berlin, Berlin, Germany
b Department of Congenital Heart Disease—Pediatric Cardiology, German Heart Center of Berlin, Berlin, Germany

Accepted for publication July 12, 2007.

* Address correspondence to Dr Delmo Walter, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, Berlin, 13353, Germany (Email: delmo-walter{at}dhzb.de).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: Surgery for mitral valve endocarditis in children is relatively uncommon. This study assesses its operative outcome and reoperation and long-term survival rates.

Methods: We reviewed the cases of 8 consecutive children who underwent mitral valve repair for infective endocarditis between 1989 and 2005 at our institution. Mean age was 13.8 years (range, 9.4 to 16.9 years). The mitral valve was affected in all 8 patients, and both aortic and mitral valve in 2. Congenital cardiac malformation was the predisposing factor in 3 patients. Three patients had floppy mitral valve owing to leaflet perforation. All 8 patients had severe mitral regurgitation. Indications for operations were cardiac failure in 2, septic embolization in 2, and severe mitral regurgitation in 4. Four surgical interventions were elective, two were urgent, and two were emergencies. The offending microorganism was identified in 7 of the 8 patients. Mitral valve repair or reconstruction was performed in all 8, and 2 patients had additional aortic valve replacement. Follow-up was complete (mean, 9.5 years; range, 0.67 to 16 years; total, 76.7 patient-years).

Results: There were no operative deaths. Actuarial freedom from reoperation and actuarial survival rate at 1, 5, 10, and 15 years were 100%. Early echocardiographic follow-up showed 4 patients to have mild mitral valve regurgitation, 2 had mild to moderate, and 2 had no regurgitation. Long-term follow-up showed no progression of the lesions.

Conclusions: Mitral valve repair achieves excellent results and can be performed without morbidity or mortality. Functional improvement and follow-up echocardiography evaluating the degree of mitral valve regurgitation and stenosis are satisfactory.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Infective endocarditis occurs less commonly in children [1, 2]. Children with untreated congenital cardiac disease, especially those with ventricular septal defect and patent ductus arteriosus, are considered to be at higher risk [3, 4] as well as children with complex intracardiac abnormalities undergoing surgical palliation or definitive correction [5]. Although improved outcomes have been reported during the past decades, infective endocarditis in infancy and childhood remains a most serious condition. Hospital mortality rates after medical treatment alone still range from 10% to 20% [5–7]. Variable perioperative death rates of 1% to 50% occur with surgical intervention, frequently used as a last resort in severely compromised patients [8–10]. In the current era, mortality rate after surgical treatment of infective endocarditis is less than 5%.

This report describes our own experience with mitral valve endocarditis in children in whom mitral valve repair was performed.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
The Institutional Review Board approved the retrospective study and waived the need for patient consent.

Between November 1989 and November 2005, we surgically treated 435 pediatric patients (age younger than 18 years) with mitral valve diseases, 171 (39%) of whom underwent mitral valve surgery for either congenital or acquired mitral valve diseases. Only 8 patients (4.7%) underwent mitral valve repair or reconstruction for infective endocarditis. Clinical records were reviewed for patient demographic data, clinical presentation, microbiologic and echocardiography data, operative findings, surgical technique used, postoperative course, and follow-up. There were 4 female and 4 male patients with a mean age of 13.8 years (range, 9.4 to 16.9 years).

Follow-Up
Data on patients’ preoperative clinical profile, operations, clinical course, pathologic, microbiologic, survival, and follow-up course were obtained through a detailed review of hospital medical records. Follow-up data were provided by the Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, and by the referring physicians. Additional information was sought from the referring physician, family doctors, or the patients’ families.

Statistical Analysis
All data were analyzed with the SPSS 12.0 software program (SPSS Inc, Chicago, IL). Our analysis was mainly descriptive. The data are expressed as absolute and percentage frequency values and continuous data as mean ± standard deviation, as appropriate.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Preoperative Clinical and Pathologic Profile
All 8 patients had native valve endocarditis. The mitral valve was primarily infected in all 8, but 2 patients had aortic valve involvement as well. Fever in all patients was the most common symptom, being present for a mean duration of 36.9 ± 20.8 days (range, 0 to 128 days).

Congenital cardiac disease, such as chordal agenesis and hammock valve, was encountered in 1 patient with severe mitral regurgitation. Aside from 2 patients who had associated congenital bicuspid aortic valve diseases, the other 6 patients had primarily isolated mitral regurgitation from infective endocarditis. No other predisposing factors were identified except in 2 children who had had dental extractions. Preoperative echocardiography showed leaflet perforation in 2 patients and vegetation in 3 patients. Three patients had cerebral embolization. No prior surgery had been performed in any of the 8 patients. The demographic, clinical, and laboratory data of the patients are presented in Table 1.


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  		Table 1 Demographic Profile of Patients
 
The offending pathogens were identified in 7 patients (Staphylococcus aureus in 1, Streptococcus viridans in 2, Streptococcus β-hemolyticus in 1, Streptococcus mitis in 2, and Pneumococcus meningitis in 1). The mean duration of antibiotic treatment preoperatively was 20.9 ± 11.7 days (range, 5 to 56 days).

The most common indication for surgery was severe valve dysfunction in 4 patients, congestive heart failure in 1, acute cardiorespiratory compromise in another who underwent surgery urgently after cardiorespiratory arrest, and septic embolization in 2 patients (Table 2).


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  		Table 2 Urgency and Indications for Operations
 
Surgery and Intraoperative Findings
Four operations were carried out during the acute and 4 during the chronic phase of the disease process, with 2 emergency, 2 urgent, and 4 elective procedures. All operations were performed through a median sternotomy under cardiopulmonary bypass and moderate systemic hypothermia. Antegrade intermittent cold-crystalloid cardioplegia with topical hypothermia was used for myocardial protection. The approach in all patients was through a left atriotomy posterior to the interatrial groove, and the annulus, leaflets, chordae tendineae, and papillary muscles were exposed and meticulously inspected to determine the extent of valvular and subvalvular damage from infective endocarditis and to plan the procedure. Our protocol prescribes the preservation of the native valve and avoidance of prosthetic materials whenever possible. Standard operative principles were the adequate debridement of all infected tissues, meticulous washing of all affected areas with 7.5 g of Povidone solution with 10% available iodine solution (Betadine) performed on all patients irrespective of the presence or absence of purulence or vegetations, and reconstruction using untreated autologous pericardium.

Mitral valve reconstruction was performed as follows: anterior commissuroplasty (Kay-Wooler technique, Fig 1) in 2 patients, posterior commissuroplasty with leaflet resection (Paneth technique, Fig 2) in another 2 patients, Hetzer-modified Paneth technique (Paneth combined with pericardial strip reinforcement, Fig 3) in 3 patients, and chordal rupture repaired by chordal reimplantation in 1 patient. We used untreated autologous pericardial pledgets instead of felt for suture reinforcement. Leaflet perforations, when found, were closed either directly or with an untreated pericardial patch. Meticulous removal of vegetations was performed when indicated. In 2 patients, attempts to reconstruct the aortic valve were unsuccessful after intraoperative transesophageal echocardiography showed unsatisfactory functional results, and it was eventually replaced. Mean cardiopulmonary bypass and ischemic times were 100.12 ± 42.9 minutes (range, 57 to 172 minutes) and 56.25 ± 26.17 minutes (range, 27 to 104 minutes), respectively (Table 3).


Figure 1
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  		Fig 1. (Left) Modified Kay-Wooler annuloplasty. (Right) Completed repair.

 

Figure 2
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  		Fig 2. Posterior annulus shortening plasty for posterior annular dilatation (Paneth technique).

 

Figure 3
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  		Fig 3. (Top) Posterior annulus shortening plasty for posterior annular dilatation reinforced with autologous pericardial strip (Hetzer modification). (Bottom) Completed repair.

 

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  		Table 3 Operative Findings, Technique of Mitral Valve Repair, Concomitant Procedures, and Perioperative Complications
 
Saline injection through the valves and intraoperative transesophageal echocardiography were performed in all patients to assess the adequacy of repair. Follow-up assessment with transthoracic echocardiography was carried out annually or if clinically indicated on the basis of symptomatology. The degree of mitral valve regurgitation was estimated by means of standard techniques.

Regardless of the underlying disease and techniques used, no patient was discharged from the hospital with more than mild mitral regurgitation.

Mortality and Morbidity
There was no operative mortality or morbidity. Mean hospital stay duration was 11.25 ± 3 days (range, 8 to 15 days). Antibiotic treatment was continued postoperatively for a mean of 46.12 ±11.4 days (range, 29 to 57 days).

Follow-Up
Follow-up was complete for all patients with a mean of 9.5 years (range, 0.67 to 16 years) and a total of 76.7 patient-years. No patient was lost to follow-up.

Early echocardiographic follow-up showed 2 patients without mitral valve regurgitation, 4 patients with mild regurgitation, and 2 with mild to moderate regurgitation. Long-term follow-up showed no progression of the lesions (Table 4). Three of the female patients had become mothers of healthy children.


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  		Table 4 Perioperative Comparison of Degree of Mitral Valve Disease and Reoperation
 
Actuarial freedom from reoperation and actuarial survival rate at 1, 5, 10, and 15 years were 100%.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
In this small series, we have shown that mitral valve repair in children with infective endocarditis is safe, with no operative and long-term mortality. All patients had good functional status during long-term follow-up, and not one had undergone mitral valve reoperation. In our institution, mitral valve reconstruction is the preferred technique for any kind of mitral disease in infants, children, and adolescents. This avoids the need for valve replacement and all its drawbacks, particularly in children, in the face of the complete lack of a prosthesis suitable for this age group. Even when the primary repair result is not optimal, time can be gained for eventual repeated repair until a definitive adult-size prosthesis can be implanted. We believe that reconstruction allows for valve growth, without the need for anticoagulation and with very little thrombotic risk. Reconstruction is best achieved using a spectrum of repair techniques applied individually and avoiding any kind of prosthetic material.

The goals of surgery are to eradicate the focus of infection, to repair destroyed valve structures, to prevent the development of complications, and to prevent relapse of the infection. Mitral valve repair also has the advantage of preserving the subvalvular apparatus and ventricular function. As ventricular function is impaired at the time of operation, any preservation of function should achieve a reduction of operative mortality and improve postoperative remodeling and long-term survival.

Although infective endocarditis is an uncommon infection in the pediatric population, it is a serious problem once it occurs. Although it is said to be predominant in male children, we have an equal sex distribution in our series. A bicuspid aortic valve is said to be the most frequent predisposing condition, followed by ventricular septal defect, patency of the ductus arteriosus, and tetralogy of Fallot [5]. Among our patients, 2 presented with pathologic alterations not only of the mitral valve but also of the aortic valve, which was bicuspid and consequently required additional attempted aortic valve repair then replacement.

Surgical treatment of infective endocarditis is necessary in patients who respond poorly to antibiotics or experience septic emboli with annular abscess or hemodynamic instability, and in those who are bacteriologically treated but in whom mitral insufficiency has developed as a result of valve destruction during infection.

Reconstruction of the mitral valve is a widely accepted surgical concept [11, 12]. This procedure has become a standard technique in patients with endocarditis only during recent years. Among the first to present data relating to successful mitral valve reconstruction in patients with acute endocarditis were Dreyfus and colleagues [13] who recommended early surgical intervention. In a study of 22 patients with active and healed endocarditis, Pagani and associates [14] found excellent early postoperative findings with respect to function and survival. Hendren and colleagues [15] presented a patient series with acute and healed endocarditis. Mean follow-up was 2 years, the early mortality rate was 9%, 85% of the patients were in New York Heart Association functional class I, and all patients were free of reinfections and alive at the time of follow-up. They concluded that mitral valve reconstruction was an attractive alternative to replacement. Both Carpentier [11] and Dreyfus and coworkers [13] recommended aggressive surgical intervention in infective valve disease consisting of debridement of the infected valve at an early stage while the infection is still limited to the heart valve tissue and before impairment of ventricular function occurs. They believed that the preservation of ventricular function is of primary importance and may be an adjunct in reducing operative mortality and morbidity by preserving functional status.

Annuloplasty is recommended when the mitral annulus is dilated to obtain a good surface of coaptation between the two leaflets. We refrain from using a prosthetic ring to support the annuloplasty as much as possible. Instead we used an autologous pericardial strip to reinforce the annulus or as pledgets for suture reinforcement, which had two distinct advantages: first, that no prosthetic material was introduced into the infective operating field, and second, that the need for anticoagulation was obviated. As there was no recurrence of endocarditis in our series, the advantage of using autologous pericardium remains speculative. In complex mitral valve reconstruction, its use also attenuates the mechanical stress on the suture lines. The most complex repairs were in 6 patients who underwent extensive resections of both leaflets with commissural reconstruction and papillary muscle division and reimplantation as well as chordal shortening. In most centers, these valves would have been replaced.

With the absence of endocarditis recurrence and total freedom from any reoperation in our series, the advantage of using different valve reconstruction techniques—Kay Wooler and Paneth annuloplasty, Hetzer-modified Paneth technique—as indicated, as well as careful reconstruction of damaged leaflet and subvalvular apparatus, meticulous debridement, and removal of vegetations, is evident. No complications comparable to those reported in other series [16] were observed. As mitral valve repair preserves viable native tissues that are more resistant to infection than prosthetic material, this may explain our excellent postoperative outcome.

Although we found preoperative evidence of cerebral embolization and vegetations in 37.7% of our patients, there was no incidence of new occurrence or progression of the existing lesions. In contrast, Kanter and Hart [17] have shown a high incidence of neurologic complications (41%) of left-sided native valve endocarditis. This incidence is even higher in patients with S aureus infections (67%). However, in our patient series, no neurologic complications occurred with an S aureus infection.

Several studies have shown congestive heart failure [18], cardiogenic shock before surgery [19], staphylococcal infection [20–22], and annular abscess [23, 24] to be factors associated with high perioperative mortality in endocarditis patients. One of our 8 patients with mitral valve endocarditis was admitted because of congestive heart failure. Another was already in cardiogenic shock and had to be resuscitated before surgery, and 1 had an identified S aureus infection. All of them required an aggressive approach to valve preservation, and all of them did well postoperatively. Hence we recommend prompt surgical treatment once confirmed that the mitral valve is affected by infective endocarditis in children to prevent further valvar damage, because native valve endocarditis begins on the native leaflet and remains there for some time before extending to the surrounding tissue.

At the last follow-up, echocardiography showed that in 100% of patients the degree of mitral valve lesions did not progress from the discharge echocardiography. The 10-year survival rate was 100%, which surpasses all other reported series. Long-term follow-up shows no progression of mitral valve disease or recurrence of endocarditis. Our experience suggests that our technique of adequate debridement of the infected tissues, washing of the affected areas with povidone-iodine solution, repair of the resulting defects with autologous pericardium, and aggressive valve reconstruction using appropriate methods results in lengthy freedom from recurrent infection and reoperation.

Mitral valve repair for children with infective endocarditis can be performed without morbidity or mortality. This surgical therapy offers optimal ventricular remodeling owing to preservation of the valvular and subvalvular apparatus, absence of reinfection, and, in general, a lack of any anticoagulation therapy requirement. Long-term follow-up shows that functional improvement and follow-up echocardiography evaluating the degree of mitral valve regurgitation and stenosis are highly satisfactory. No patients were reoperated on for the same mitral valve disease or for any other valve problems for that matter, indicating that the surgical techniques we used were suitable to produce a satisfactory, long-lasting solution. We believe that our small collection of patients seen over the course of 16 years in whom mitral valve repair was performed will be helpful in guiding clinical perspectives in children with infective endocarditis.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
We thank Anne Gale, Astrid Behennour, Christine Detschadse, Daniela Moeske-Scholz, and Heike Schultz for assistance with this article.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Tansel T, Onursal E, Eker R, Ertugrul T, Dayioglu E. Results of surgical treatment for infective endocarditis in children Cardiol Young 2005;15:621-626.[Medline]
  2. Humpl T, McCrindele BW, Smallhorn JF. The relative roles of transthoracic compared with transesophageal echocardiography in children with suspected endocarditis J Am Coll Cardiol 2003;41:2068-2071.[Abstract/Free Full Text]
  3. Fisher MC. Changing risk factors for pediatric infective endocarditis Curr Infect Dis Resp 2001;3:333-336.
  4. Ferrieri P, Gewitz MH, Gerber MA, et al. Unique features of infective endocarditis in childhood Pediatrics 2002;109:931-943.[Free Full Text]
  5. Alexiou C, Langley SM, Monro J. Surgery for infective valve endocarditis in children Eur J Cardiothoracic Surg 1999;16:653-659.[Abstract/Free Full Text]
  6. Martin JM, Neches WH, Wald ER. Infective endocarditis: 35 years of experience at a children’s hospital Clin Infect Dis 1997;24:669-675.[Medline]
  7. Normand J, Bozio A, Etienne J, Sassolas F, LeBris H. Changing patterns and prognosis of infective endocarditis in childhood Eur Heart J 1995;16:28-31.[Abstract/Free Full Text]
  8. Fukushige J, Iragashi H, Ueda K. Spectrum of infective endocarditis during infancy and childhood: 20-year review Pediatr Cardiol 1994;15:127-131.[Medline]
  9. Picarelli D, Leone R, Duhagon P, et al. Acute infective endocarditis in infancy and childhood: ten year review of surgical therapy J Card Surg 1997;12:406-411.[Medline]
  10. Nomura F, Penny DJ, Manahem S, Pavade A, Karl TR. Surgical intervention for infective endocarditis in infancy and childhood Ann Thorac Surg 1995;60:9-15.
  11. Carpentier A. Cardiac valve surgery: the "French connection." J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
  12. Muehrcke DD, Cosgrove DM, Lyle BW, et al. Is there an advantage to repairing infected mitral valves? Ann Thorac Surg 1997;63:1718-1724.[Abstract/Free Full Text]
  13. Dreyfus G, Serraf A, Jebara VA, et al. Valve repair in acute endocarditis Ann Thorac Surg 1990;49:706-713.[Abstract]
  14. Pagani FD, Monaghan HL, Deeb GM, Bolling SF. Mitral valve reconstruction for active and healed endocarditis Circulation 1996;94(Suppl 2):II-133-II-138.[Medline]
  15. Hendren WG, Morris AS, Rosenkranz ER, et al. Mitral valve repair for bacterial endocarditis J Thorac Cardiovasc Surg 1992;103:124-129.[Abstract]
  16. Zegdi R, Debieche M, Latremouille C, et al. Long-term results of mitral valve repair in active endocarditis Circulation 2005;111:2532-2536.[Abstract/Free Full Text]
  17. Kanter MC, Hart RG. Neurologic complication of infective endocarditis Neurology 1991;41:1015-1020.[Abstract/Free Full Text]
  18. Verheul H, Van den Brink RBA. Effects of changes in management of active infective endocarditis on outcome in 25-year period Am J Cardiol 1993;72:682-687.[Medline]
  19. Jault F, Gandjbakhch I, Rama A, et al. Active native valve endocarditis: determinants of operative death and late mortality Ann Thorac Surg 1997;63:1737-1741.[Abstract/Free Full Text]
  20. D’Agostino RS, Miller DC, Stinson EB, et al. Valve replacement in patients with native valve endocarditiswhat really determines operative outcome?. Ann Thorac Surg 1985;40:428-438.
  21. Mullany CJ, Chua YL, Schaff HV, et al. Early and late survival after surgical treatment of culture-positive active endocarditis Mayo Clin Proc 1995;70:517-525.[Abstract]
  22. Al Jubair K, Al Fagih M, Ashmeg A, Belhaj M, Sawyer W. Cardiac operations during acute endocarditis J Thorac Cardiovasc Surg 1992;104:487-490.[Abstract]
  23. Kimose HH, Lund O, Kroman-Hansen O. Risk factors for early and late outcome after surgical treatment of native infective endocarditis Scan J Thorac Cardiovasc Surg 1990;24:111-120.[Medline]
  24. Mullany CJ, McIsaacs AI, Rowe MH, Hale GS. The surgical treatment of infective endocarditis World J Surg 1989;13:132-136.[Medline]



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This Article
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