Ann Thorac Surg 2009;88:269-271. doi:10.1016/j.athoracsur.2008.11.067
© 2009 The Society of Thoracic Surgeons
Case Reports
Mitral Valve Repair by Leaflet Sliding and Annular Downsizing in Active Infective Endocarditis
Masayoshi Umesue, MD, PhD*,
Takashi Matsumoto, MD,
Kanzi Matsui, MD, PhD
Cardiovascular Surgery, Matsuyama Red Cross Hospital, Ehime, Japan
Accepted for publication November 26, 2008.
* Address correspondence to Dr Umesue, Cardiovascular Surgery, Matsuyama Red Cross Hospital Bunkyouchou 1, Matsuyama, Ehime, 790-8524, Japan (Email: umesue{at}matsuyama.jrc.or.jp).
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Abstract
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We repaired a large defect in the posterior mitral leaflet after an extensive removal of infected tissue, using an extended leaflet sliding and annular downsizing with a small prosthetic ring in 2 patients with active endocarditis.
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Introduction
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Although mitral repair is the well-established procedure to treat mitral regurgitation in degenerative valves, repair is often not feasible in an active endocarditis because of inadequate remnant tissue after a radical débridement and valve destruction by the responsible organism. We believe sliding repair, supported by a small prosthetic ring, extends the possibility of repair in active endocarditis patients.
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Case Reports
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Patient 1
A 36-year-old man was operated on for recurrent emboli and persistent vegetation on the mitral valve despite appropriate antibiotic therapy for the causative organism, methicillin sensitive Staphylococcus aureus. The vegetation was 30 x 15 mm and was attached to the posteromedial scallop (P3), posterior annulus, and left atrial endothelium. Radical resection of all infected tissue resulted in the loss of the whole of P3, including its annulus and the surrounding left atrial endothelium.
We performed annular reconstruction by placing mattress sutures of 2-0 polyester along the defect in the annulus with an autologous pericardial strip on the ventricular side. The residual anterolateral (P1) and middle scallop (P2) were entirely detached from the annulus, leaving an attachment at the anterolateral commissure, and were reattached to the whole posterior annulus, including the reconstructed annulus, with a running 5-0 polypropylene suture (Figs 1A–D). The mitral annulus, measured with a sizer for a Carpentier-Edwards Physio Ring (Edwards Lifesciences, Irvine, CA), was 28 mm; hence, a 26-mm Physio Ring was used for downsizing the mitral annulus (Fig 1E).
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Fig 1. (A) Vegetation (black area) was attached to the posteromedial scallop, posterior annulus, and left atrial endothelium. (B) Resection of vegetation and surrounding tissue is indicated by dotted area. Residual posterior was detached from its annulus, leaving attachment at the anterolateral commissure. (C) Annular reconstruction was performed with an autologous pericardial strip on the ventricular side. (D) The detached posterior leaflet was reattached to the whole posterior annulus, including the reconstructed annulus. (E) Annular downsizing was undertaken using a 26-mm prosthetic ring.
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Saline testing showed symmetrical coaptation with no regurgitation. Intraoperative transesophageal echocardiography revealed no mitral regurgitation. The valve area was 2.0 cm2. The patient has been followed up for 18 months and is in New York Heart Association (NYHA) functional class I.
Patient 2
A 54-year-old man with known asymptomatic mitral prolapse presented with infective endocarditis caused by Streptococcus sanguis with vegetation on the posterior mitral valve. Torn chordae were causing severe regurgitation. An operation was indicated for progressive heart failure and resistance to antibiotic therapy.
During the operation, the vegetation attached to the P2 was measured at 30 x 5 mm. The adjacent parts of P1 and P3 were edematous. A small area of the anterior leaflet facing the vegetation was also edematous. The entire P2 and adjacent one-third of P1 and P3 were quadrangularly resected. As a consequence, approximately the central five-ninths of the posterior leaflet was removed, leaving a large defect.
After extensive resection, the remnant segments of P1 and P3 were entirely detached from their annulus, leaving an attachment at the commissure for sliding. The bottom tips of the remnant leaflets were reapproximated, and the leaflets were reattached to the annulus with double over-and-over stitches of 5-0 polypropylene suture. Two edges of the remnant leaflets were reapproximated with interrupted stitches of 5-0 polypropylene suture. The edematous part of the anterior leaflet was resected into a wedge shape, including an attaching chord, and the edges were reapproximated with interrupted stitches of 5-0 polypropylene suture (Fig 2A–C).
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Fig 2. (A) Vegetation (black area) was attached to the middle scallop, and adjacent parts of anterolateral and posteromedial scallop were edematous. A small area of the anterior leaflet facing the vegetation was also edematous (dotted area). (B) Quadrangular resection resulted in a large defect of the posterior leaflet. The edematous part of the anterior leaflet was resected into a wedge shape. Remnant segments of anterolateral and posteromedial scallops were entirely detached from their annulus, leaving an attachment at the commissure for sliding. (C) The bottom tips of the remnant leaflets were reapproximated and the leaflets reattached to the annulus. The two edges of remnant leaflets were reapproximated. (D) The mitral annulus was downsized using a 24-mm annuloplasty ring (Edwards Lifesciences, Irvine, CA).
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Saline testing showed symmetrical coaptation with mild central regurgitation. The mitral annulus measured 26 mm; hence, mitral annulus downsizing was done using a 24-mm Physio Ring (Fig 2D; Edwards Lifesciences). Saline testing after the annuloplasty indicated no regurgitation. Intraoperative transesophageal echocardiography showed no regurgitation. The valve area was 1.6 cm2. The patient has been followed up for 28 months and is in NYHA class I.
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Comment
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The principle of surgical intervention for active endocarditis is complete resection of infected tissue. Possibility of repair is not a consideration; therefore, valve repair is often not feasible because of an inadequate amount of remnant tissue after radical resection. Destruction by the causal organism also hinders repair of the infected valve. Prosthetic valve replacement has been the standard therapy for endocarditis for many years. Meanwhile, valve repair has become a well-established procedure to treat degenerative mitral regurgitation. Recently, mitral valve repair has been reported as the preferred treatment, even in acute endocarditis, when feasible [1].
The sliding repair was originally developed to prevent systolic anterior movement of the mitral leaflets after a quadrangular resection for degenerative posterior leaflet [2]. Subsequently, leaflet sliding to treat prolapse of paracommissural area was also reported [3]. We adopted an extended sliding repair and annular downsizing using a prosthetic ring to maintain valve competency. This reduces tension on the stretched posterior leaflet after an extensive leaflet resection; otherwise, the large defect could not be filled with remnant posterior leaflet tissue without distortion or overstretch.
The mitral annulus is not dilated in most patients with acute endocarditis, and the annular plication renders the mitral valve area reasonably narrower than the native valve. At the same time, given that a prosthetic valve is implanted in the nondilated annulus, the effective orifice area is still significantly smaller than the native valve. The effective orifice area of the most standard mechanical or bioprosthesis prosthetic valve available of 25 mm ranges from 1.36 to 2.2 cm2 and that of 27-mm prosthetic valves is 1.53 to 2.2cm2 [4]. Hence, we think the annular plication is a reasonable investment to preserve the mitral valve and avoid lifelong anticoagulation therapy associated with a mechanical valve, if selected.
Use of a prosthetic ring is controversial in acute endocarditis. Because the extensive leaflet excision and subsequent leaflet sliding significantly reduce the height of the posterior leaflet, we believe the prosthetic ring is necessary to gain a sufficient coaptation by reducing the anterior–posterior diameter of the mitral valve. Although an autologous pericardial strip instead of prosthetic ring might lower the possibility of endocarditis recurrence, we consider the pericardial strip is insufficient to reduce anterior–posterior diameter and compromises the repair.
Although long-term evaluation is needed, the combined procedure of extended leaflet sliding and annular plication with a prosthetic ring provides an early durable and predictable repair for an active mitral endocarditis that might otherwise need replacement.
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References
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- Ruttmann E, Legit C, Poelzl G, et al. Mitral valve repair provides improved outcome over replacement in active infective endocarditis J Thorac Cardiovasc Surg 2005;130:765-771.[Abstract/Free Full Text]
- Jebara VA, Mihaileanu S, Acar C, et al. Left ventricular outflow tract obstruction after mitral valve repair. Results of the sliding leaflet technique. Circulation 1993;88:II30-II34.[Medline]
- van Herwerden LA, Taams MA, Bos E. Repair of commissural prolapse by extended leaflet sliding Ann Thorac Surg 1994;57:387-390.[Abstract/Free Full Text]
- Magne J, Mathieu P, Dumesnil JG, et al. Impact of prosthesis-patient mismatch on survival after mitral valve replacement Circulation 2007;115:1417-1425.[Abstract/Free Full Text]
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Abstract
Introduction
