Ann Thorac Surg 2008;86:291-293. doi:10.1016/j.athoracsur.2008.01.067
© 2008 The Society of Thoracic Surgeons
Case Reports
Modified De Vega Mitral Valve Annuloplasty in an Infant With Endocarditis
Michael L. Ciccolo, MDa,b,
Juan C. Collazos, MDc,d,
Ruben J. Acherman, MDc,d,
Alvaro Galindo, MDc,d,
Carlos F. Luna, MDc,d,
Humberto Restrepo, MD, MPHc,d,*,
William N. Evans, MDc,d
a Cardiovascular Surgical Associates, Las Vegas, Nevada
b University of Nevada School of Medicine, Las Vegas, Nevada
c Department of Pediatrics, Las Vegas, Nevada
d Children's Heart Center, Las Vegas, Nevada
Accepted for publication January 23, 2008.
* Address correspondence to Dr Restrepo, Children's Heart Center, 3006 S Maryland Pkwy, Ste 690, Las Vegas, NV 89109 (Email: hurescan{at}gmail.com).
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Abstract
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Surgical management of infant mitral valve regurgitation is challenging. There are no large surgical series of mitral valve repair in infants. Mitral valve repair is preferable to replacement. We report the modified De Vega adjustable annuloplasty with mitral valve repair in an infant with mitral valve regurgitation from endocarditis.
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Introduction
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The surgical management of infants with mitral valve regurgitation (MVR) includes MV replacement, repair, and annuloplasty. Principal causes of MVR include congenital MV abnormalities and endocarditis. We report an infant in whom endocarditic MVR developed after total anomalous pulmonary venous return repair. Treatment consisted of the use of a modified De Vega adjustable annuloplasty.
Echocardiography in a 24-hour-old, 1.7-kg, 33-week-gestation infant demonstrated total anomalous pulmonary venous return to the right atrium. At 33 days of life, she underwent deep hypothermic circulatory arrest repair that redirected the pulmonary veins entering the dome of the right atrium through an intraatrial pericardial patch. She went home 5 days later with a normal discharge echocardiography, without pulmonary venous obstruction.
She was readmitted 3 days later for fever. Results of echocardiography were normal, without MVR. After a positive blood culture for Enterococcus faecalis 4 days later, an echocardiography demonstrated a 5- x 2-mm posterior leaflet MV vegetation with mild central MVR. Sensitivities led to treatment with ampicillin and gentamicin. Acute-phase reactants and white blood cell counts improved. Blood cultures became negative.
Nonetheless, mild MVR progressed to moderate, necessitating medical therapy for congestive heart failure (CHF). She was discharged after 13 days with an indwelling catheter for a 6-week course of intravenous antibiotics. During outpatient follow-up, 6 consecutive echocardiographies showed no change in the vegetation size. The MVR improved to mild. Because MVR and CHF were stable, she did not undergo vegetectomy.
Three weeks after we discontinued antibiotics, at 4 months old, she was admitted after an apneic episode. Then, an echocardiography showed moderate MVR, and left atrial and left ventricular enlargement. The vegetation had grown to 9 x 5 mm and appeared echodense, suggesting calcific changes. Despite negative blood culture results, we treated her with ampicillin, gentamicin, and rifampin. Two weeks into this admission, an echocardiography demonstrated severe central MVR and stable vegetation size. Despite maximal CHF medical therapy, respiratory failure led to mechanical ventilation, at which time we proceeded with MV surgical repair.
Cardiopulmonary bypass with bicaval cannulation, aortic cross-clamping, and antegrade cardioplegia were initiated. The Guiraudon-transseptal approach was used to expose the anterior and posterior MV leaflets (AML, PML) [1]. A 9- x 5-mm calcified vegetation was originating from the central free edge of the PML, associated with calcified ruptured chordae (Fig 1). The PML also had small perforations. The AML chordae appeared attached and functional, but the anterolateral portion had a linear tear.
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Fig 1. Diagram (A) before the modified De Vega adjustable annuloplasty (AA) and (B) after the procedure. (ALPM = anterolateral papillary muscle; AML = anterior mitral valve leaflet; AMPL = anterior mitral leaflet; P = perforations; PML = posterior mitral leaflet; PMPM = posteromedial papillary muscle; R = portion of posterior leaflet resected; T = tear; V = vegetation.)
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The vegetation was excised, and the perforations were closed individually with 6-0 Prolene (Ethicon, Somerville, NJ) suture. Pathology showed calcified nodules, inflammatory cells, and no organisms on Gram stain. The AML tear was sutured with running 6-0 Prolene in two layers. Because the central part of PML was flail, a quadrangular resection of this area required closure with running 6-0 Prolene suture. A Carpentier annuloplasty was not performed because the tissue removed was minimal at the annular level and maximal at the free edge of the PML segment.
A saline load after the repair demonstrated moderate MVR; therefore, a modified De Vega adjustable annuloplasty was performed using 5-0 Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) polytetrafluoroethylene suture. The annuloplasty suture ran posterior to the MV, starting at the anterolateral commissure and to the posteromedial commissure, bringing the sutures out near the left atrium on the left side of the inferior vena cava. Rommel snares were placed for annuloplasty adjustment. Upon coming off cardiopulmonary bypass, moderate MVR persisted by transesophageal echocardiography (TEE) but decreased to mild on tightening the annuloplasty. The annuloplasty sutures were secured by multiple knots and clips to prevent slippage. The TEE at the conclusion of the repair demonstrated mild mitral stenosis (peak pulsed-Doppler inflow velocity, 1.6 m/s) and 1+ MVR. Four-month follow-up has shown no change in the immediate postoperative findings.
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Comment
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Serious MVR with CHF, despite maximal medical therapy, may require surgical intervention. Infant MV replacement poses difficulties, including MV annular size, long-term anticoagulation, and multiple reoperations to upsize or replace a malfunctioning prosthetic MV. Replacing the MV with bacterial endocarditis creates further risks.
The reported reoperation rate for MV replacements in infants within 6 years is 36%, with a 5-year survival rate of 43% [2]. In children aged younger than 1 year, however, repair of congenital MV disease has good results, with a 7-year survival rate of 94% and a reoperation rate of 42% at 7 years [3]. In infants, MV repair for MVR is thus preferable to MV replacement.
In 1972, De Vega [4] described a tricuspid annuloplasty technique using synthetic suture. In 1987, Kurlansky and colleagues [5] modified the De Vega technique to allowed for annuloplasty adjustment after discontinuation of cardiopulmonary bypass.
Kanter and colleagues [6] reported the successful use of the De Vega technique to relieve tricuspid insufficiency in 41 pediatric patients. Their results showed only 4 patients (9.5%) with early postoperative persistent moderate or severe tricuspid regurgitation. After 3 years, only 2 patients had had reoperations. They concluded the technique might fail in those with significant residual or recurrent right ventricular hypertension [6].
Anagnostopoulos and colleagues [7] recently reported using the De Vega annuloplasty procedure for successfully repairing the MV annulus in an infant with congenital MVR.
Two case reports have been published that document a single infant undergoing MV surgery for endocarditis. One report described using the Kay-Reed annuloplasty technique and the second reported using MV leaflet reconstruction with fresh autologous pericardium [8, 9]. We chose to use the modified De Vega adjustable annuloplasty, which we believe provided better relief of MVR than mattress sutures to the MV commissures because the De Vega procedure produced a tight, even posterior MV annuloplasty.
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References
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- De Vega N. Selective, adjustable and permanent annuloplasty. An original technic for the treatment of tricuspid insufficiency. Rev Esp Cardiol 1972;25:555-556.[Medline]
- Kurlansky P, Rose EA, Malm JR. Adjustable annuloplasty for tricuspid insufficiency Ann Thorac Surg 1987;44:404-406.[Abstract]
- Kanter KR, Doelling NR, Fyfe DA, Sharma SH, Tam VKH. De Vega tricuspid annuloplasty for tricuspid regurgitation in children Ann Thorac Surg 2001;72:1344-1348.[Abstract/Free Full Text]
- Anagnostopoulos PV, Alphonso N, Nolke L, et al. Neonatal mitral and tricuspid valve repair for in utero papillary rupture Ann Thorac Surg 2007;83:1458-1462.[Abstract/Free Full Text]
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- Healy DG, Wood AE. Anterior mitral leaflet reconstruction with pericardium in a 1.9 kg infant with endocarditis Ann Thorac Surg 2006;81:2310-2312.[Abstract/Free Full Text]
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Abstract
Introduction
