Ann Thorac Surg 2009;88:e14-e15. doi:10.1016/j.athoracsur.2009.04.127
© 2009 The Society of Thoracic Surgeons
Case Reports
Repair of Concomitant Valvular Endocarditis Using a Single Homograft
Yong G. Peng, MD, PhDa,*,
Tomas Martin, MDb,
Todd Horowitz, DOa,
Avner Sidi, MDa,
Gregory Janelle, MDa
a Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
b Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
Accepted for publication April 21, 2009.
* Address correspondence to Dr Peng, Department of Anesthesiology, PO Box 100254, Gainesville, FL 32610-0254 (Email: ypeng{at}anest.ufl.edu).
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Abstract
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Definitive treatment of complicated bacterial endocarditis requires surgical operation. However, the extent of bacterial endocarditis has dictated that surgical options be individualized. There are several surgical approaches to treat bacterial endocarditis. Transesophageal echocardiography has provided an invaluable intraoperative aid to the surgical decision-making and quality assurance of the repair. We report a case in which a primary aortic homograft was used for concomitant aortic and mitral valve repair based on transesophageal echocardiography evaluation. This case provides a new surgical alternative that uses a single homograft to repair aortic and mitral valves.
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Introduction
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Surgical repair is considered definitive treatment for complicated bacterial endocarditis [1]. Transesophageal echocardiography (TEE) has provided an invaluable intraoperative aid to the surgical decision-making and quality assurance of the repair [2–4]. We report a case in which a primary aortic homograft was used for concomitant aortic and mitral valves repair based on the precise intraoperative TEE evaluation. This case provides a new surgical alternative that uses a single homograft to repair aortic and mitral valves.
A 37-year-old man, with a history of intravenous drug abuse presented to the emergency department with a 3-week history of bilateral lower extremity edema, intermittent fevers, night sweats, dyspnea, and orthopnea. Physical examination showed a grade IV–VI diastolic decrescendo murmur. A transthoracic echocardiographic examination showed large vegetation on the aortic valve with severe aortic insufficiency and small vegetation on the anterior leaflet of the mitral valve with moderate mitral regurgitation. The left ventricular ejection fraction was estimated to be 25% to 30%. Initial blood cultures were positive for Enterococcus faecalis, confirming the clinical diagnosis of bacterial endocarditis. He was treated with a full course of ampicillin and gentamicin.
The day of the surgery, after an uneventful anesthetic induction, a TEE probe was inserted atraumatically. A complete TEE examination showed severe aortic insufficiency with multiple mobile vegetations on the aortic valve, and moderate mitral insufficiency with a perforation of the anterior mitral leaflet (AML) (Fig 1).
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Fig 1. Aortic valvular vegetation and anterior mitral leaflet perforation demonstrated on midesophageal four chamber and left ventricular outflow tract view.
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The aortic valve and aortic root were resected, and approximately 80% of the AML was radically debrided without disruption of the papillary muscle. A 22-mm Cryo-preserved homograft was selected (Cryolife Inc, Kennesaw, GA) based on TEE measurements (Fig 2). Based on the extensive aortic and mitral valve damage and the unique anatomic relationship between the aortic root and the AML, reconstruction of both the aortic root and the damaged portion of the AML were accomplished using a single aortic homograft without disruption of the papillary muscles. The initial TEE examination prior to separation from cardiopulmonary bypass demonstrated a competent aortic valve and good mobility of the AML; however, there was moderate-to-severe mitral insufficiency due to poor central coaptation of the anterior and posterior leaflets. It was believed that the cause of mitral regurgitation was due to dilation of the mitral annulus or possibly from the creation of an uneven plane of coaptation between the two mitral leaflets relative to the annulus. Mitral annuloplasty was therefore performed with a No. 30 Carpenter-Edwards Physio Ring (Edwards Lifesciences, Irvine, CA). The follow-up TEE examination showed excellent coaptation without mitral insufficiency. The patient was weaned from cardiopulmonary bypass without difficulty.
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Comment
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This is the first reported case of primary aortic homograft use for concomitant bi-valvular repair of aortic and mitral bacterial endocarditis. This case also demonstrates the value of intraoperative TEE in guiding successful intraoperative surgical corrective procedures.
Mitral valvular involvement is an occasional complication of aortic valve bacterial endocarditis, presumably due to local extension of the abscess cavity or from seeding of the AML by the aortic insufficiency jet [5]. Both AML dissection and aneurysm formation of the AML have been reported, and antibiotic therapies have been proposed as an alternative to surgical intervention [4]. Perforation of the mitral valve leaflet, however, typically necessitates surgical repair or replacement due to the acute onset of congestive heart failure [1, 2]. The surgical options depend on the complexity of the local valvular involvement. In our case, a novel surgical approach was possible because of the unique anatomic relationship of the aortic root and the AML, coupled with the fact that the preserved aortic homograft available for the case had retained a large donor aortic curtain and accompanying AML tissue. The advantage of mitral valve repair whenever possible in acute endocarditis has been supported by others [6, 7]. Although long-term survival benefits exist for mitral valve repair versus replacement for other causes of mitral regurgitation, experience related to surgical outcomes after repair of infected mitral valves remains limited [8–11].
Transesophageal echocardiography has been shown to be a more sensitive and specific modality than transthoracic echocardiogram for detection of native valve vegetations [12-13]. Intraoperative TEE is valuable to diagnose intracardiac pathology, guide surgical treatment, and assess treatment outcomes [2–4]. Repair of valvular disease is a class I indication for intraoperative TEE [14]. Intraoperative TEE allowed our operative team to choose a novel surgical approach, evaluate the initial repair, and modify the repair based on real-time data to achieve an optimal outcome.
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References
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- Miro JM, del Rio A, Mestres CA. Infective endocarditis and cardiac surgery in intravenous drug abusers and HIV-1 infected patients Cardiol Clin 2003;21:167-184.[Medline]
- Koch CG, Milas BL, Savino JS. What does transesophageal echocardiography add to valvular heart surgery? Anesthesiol Clin North Am 2003;21:587-611.[Medline]
- Fujii H, Suehiro S, Shibata T, Hattori K, et al. Value of intraoperative transesophageal echocardiography in preventing serious complications during valvular surgery J Heart Valve Dis 2002;11:135-138.[Medline]
- Janelle GM, Mnookin SC, Thomas JJ, Paulus DA, Martin TD. Valvular pathology diagnosed with transesophageal echocardiography during aortic root replacement J Cardiothorac Vasc Anesth 2003;17:271-272.[Medline]
- Gonzalez-Lavin L, Lise M, Ross D. The importance of the "jet lesion" in bacterial endocarditis involving the left heart. Surgical considerations. J Thorac Cardiovasc Surg 1970;59:185-192.[Medline]
- Sternik L, Zehr KJ, Orszulak TA, et al. The advantage of repair of mitral valve in acute endocarditis J Heart Valve Dis 2002;11:91-97.[Medline]
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- Lawrie GM. Mitral valve repair versus replacement. Current recommendations and long-term results. Cardiol Clin 1998;16:437-448.[Medline]
- DeAnda Jr A, Kasirajan V, Higgins RS. Mitral valve replacement versus repair in 2003: Where do we stand? Curr Opin Cardiol 2003;18:102-105.[Medline]
- Roe MT, Abramson MA, Li J, et al. Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the Duke criteria Am Heart J 2000;139:945-951.[Medline]
- Reynolds HR Jagen MA, Tunick PA, Kronzon I. Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era J Am Soc Echocardiogr 2003;16:67-70.[Medline]
- Iglesias I. Intraoperative TEE assessment during mitral valve repair for degenerative and ischemic mitral valve regurgitation Semin Cardiothorac Vasc Anesth 2007;11:301-305.[Abstract/Free Full Text]
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Abstract
Introduction
