Ann Thorac Surg 2009;87:653-654. doi:10.1016/j.athoracsur.2008.05.078
© 2009 The Society of Thoracic Surgeons
How To Do It
Replacement of A2 and A3 by Pericardium Due to Endocarditis of the Anterior Leaflet of the Mitral Valve
Omar A. Araji, MD, PhD*,
Jose M. Barquero, MD,
Manuel Almendro, MD,
Maria Angeles Gutierrez, MD,
Mariano Garcia-Borbolla, MD,
Carlos J. Velázquez, MD,
Carlos A. Infantes, MD
Department of Cardiovascular Surgery, Hospital Virgen Macarena, Seville, Spain
Accepted for publication May 29, 2008.
* Address correspondence to Dr Araji, Department of Cardiovascular Surgery, Hospital Universitario Virgen Macarena, Avenida Dr Fedriani 3, Seville, 41009, Spain (Email: oharaji{at}hotmail.com).
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Abstract
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We present a case of acute endocarditis due to enterococcus faecalis involving partially A2 and completely A3 (Carpentier classification) with destruction of the free margin of the mitral valve. Repair was performed by using glutaraldehyde treated porcine pericardium to replace the defect and neochordae of polytetrafluoroethylene sutured to the free margin of the pericardium to achieve competence. Intraoperative and follow-up echocardiogaphies showed no regurgitation.
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Introduction
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Mitral valve repair is accepted as the procedure of choice for mitral regurgitation, and for cases of acute infective endocarditis complicated by abscess formation, conduction disturbances, congestive heart failure, new valvular regurgitation, and persistent fever or bacteremia despite maximal antibiotic therapy [1]. However, repair has not been described in the presence of extensive infection of the anterior leaflet including the free margin. We present a case of successful repair of the mitral valve in this situation.
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Technique
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A 30-year-old woman was seen with a 3-week history of fever, pleuritic chest pain, and progressive dyspnea. She had a systolic murmur and the blood culture was positive for enterococcus faecalis. The transesophageal echocardiography demonstrated good left ventricular function, massive mitral regurgitation, perforation, and a large vegetation on the free margin of the anterior leaflet (Fig 1). Antibiotic therapy with ampiciline and streptomycin was started 1 week before surgery.
Surgery
Surgery was performed with aorto-bi-caval cannulation, cold blood antegrade, and retrograde cardioplegia and the use of a Cosgrove retractor (Kapp Surgical Instrument Inc, Cleveland, OH) to aid access to the mitral valve through the small left atrium. Endocarditis affected more than 50% of the anterior leaflet including the free margin (Fig 2). The damaged area was excised, including all damaged chordae. A piece of porcine pericardium was cut to simulate the defect and was sutured in place using continuous 5-0 polypropylene. Three pairs of neochordae of polytetrafluoroethylene were used to achieve competence, and finally an annuloplasty with flexible 25-mm ring was performed (Fig 3). Intraoperative transesophageal echocardiography showed no regurgitation in the newly fashioned mitral valve (Fig 4).
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Fig 3. Drawing shows the patch replacement of the destructed area, the implantation of the neochordae, and the annuloplasty.
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The patient made uneventful postoperative recovery and she received 6 weeks parenteral antibiotic therapy prior to hospital discharge.
Postoperative echocardiography demonstrated a competent mitral valve with no recurrence of endocarditis. On review at 6 months, the patient was in New York Heart Association functional class I.
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Comment
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Mitral valve replacement has been the standard surgical therapy for patients with mitral valve endocarditis. More recently, attempts have been undertaken to repair the mitral valve in infective endocarditis, aiming at an improved postoperative and long-term outcome. In published studies, the feasibility of repairing infected mitral valves for acute endocarditis has been demonstrated to vary from 36% to 78% [2, 3].
Dreyfus and colleagues [4] performed mitral valve repairs according to Carpentier's techniques in patients with a large range of valvular pathologies, including those with active endocarditis involving the anterior leaflet. However, they observed that the repair of the anterior leaflet with pericardium was possible only when the marginal chordae were not involved. Cases of entire and partial anterior leaflet reconstruction with pericardium when the free margin was intact were reported [5, 6].
In our case, we have shown that despite destruction of the free margin of the anterior leaflet, repair can be achieved with pericardium and polytetrafluoroethylene neochordae to replace the affected areas 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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- Feringa Harm HH, Shaw Leslee J, Poldermans D, et al. Mitral valve repair and replacement in endocarditis: a systematic review of literature Ann Thorac Surg 2007;83:564-571.[Abstract/Free Full Text]
- Sternik L, Zehr KJ, Orszulak TA, et al. The advantage of repair of the mitral valve in acute endocarditis J Heart Valve Dis 2002;11:1-98.[Medline]
- Lung B, Paziaud JR, Cormier B, et al. Contemporary results of mitral valve repair for infective endocarditis J Am Coll Cardiol 2004;43:386-392.[Abstract/Free Full Text]
- Dreyfus G, Serraf A, Jebara VA, et al. Valve repair in acute endocarditis Ann Thorac Surg 1990;49:706-713.[Abstract/Free Full Text]
- Healy DG, Wood AE. Anterior leaflet reconstruction with pericardium in a 1.9 infant with pericarditis Ann Thorac Surg 2006;81:2310-2312.[Abstract/Free Full Text]
- Jones JM, Sarsam MA. Partial mitral valve replacement for acute endocarditis Ann Thorac Surg 2001;72:255-257.[Abstract/Free Full Text]
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Abstract
Introduction
