Ann Thorac Surg 2009;88:e29-e30. doi:10.1016/j.athoracsur.2009.06.079
© 2009 The Society of Thoracic Surgeons
How To Do It
Commissural Autologous Pericardial Patch Repair: A Novel Technique for Active Mitral Valve Endocarditis Involving the Mitral Annulus
Teruaki Ushijima, MD, PhD*,
Yujiro Kikuchi, MD,
Munehisa Takata, MD,
Yoshitaka Yamamoto, MD,
Kenji Kawachi, MD, PhD,
Go Watanabe, MD, PhD
Division of Cardiac Surgery, Tokyo Medical University, Tokyo, Japan
Accepted for publication June 9, 2009.
* Address correspondence to Dr Ushijima, Division of Cardiac Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan (Email: ushijima{at}tokyo-med.ac.jp).
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Abstract
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In patients with massive destruction caused by mitral endocarditis, surgical valve repair remains a challenging issue. Although several procedures have previously been introduced, no standard method for complicated lesions has been established. We describe a technique of mitral valve repair for extensive destructive endocarditis involving both leaflets and the mitral annulus that has provided satisfactory initial results in 2 patients. This procedure is believed to be technically simple and beneficial in terms of mitral repair for active endocarditis.
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Introduction
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Mitral valve repair is an established treatment of degenerative mitral regurgitation. In mitral valve endocarditis, recent clinical studies suggest that mitral valve repair is associated with excellent early and late results compared with valve replacement [1–3]. However, valve repair is challenging in patients with extensive active mitral valve endocarditis involving both leaflets and the mitral annulus. Although various reconstructive techniques have been introduced, no standard method for complicated lesions has been established. We describe a novel technique of commissural patch repair that was applied in patients with massive destruction of both leaflets and the mitral annulus due to active infective endocarditis.
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Technique
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The patients were placed under general anesthesia, and a median sternotomy was done. Cardiopulmonary bypass was established with bicaval venous drainage and ascending aortic return. Moderate systemic hypothermia was attained. After aortic cross-clamping, retrograde cold blood cardioplegia was applied and cardiac arrest was obtained. A transseptal atrial incision was used to approach a mitral valve in one patient and a longitudinal incision of the right side of the left atrium was used in the other patient.
All infected and damaged areas of the mitral valve, including both leaflets, were excised with a scalpel and scissors, followed by ablation of the affected surface with electric cautery (Figs 1A and B). The annulus destroyed by the abscess was aggressively débrided. Elastic stay sutures were passed around normal chordae on each excised edge of anterior and posterior leaflets. A piece of an autologous pericardial patch, which was tanned intraoperatively in glutaraldehyde solution, was cut to simulate the excised valve segment and was sutured in place using continuous 5-0 polypropylene sutures to the rim of the leaflets, the mitral annulus, and the left ventricular endocardium. The smooth surface of the pericardium was turned toward the atrium.
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Fig 1. (A) Illustration represents extended active mitral valve endocarditis involving both leaflets and the mitral annulus. (B) Radical débridement of the infected annulus and both leaflets resulted in a 50% defect in the mitral valve orifice. (C) The defect was closed with an autologous pericardial patch. The patched suture line of the annulus was reinforced with a twisted pericardial strip.
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An additional stitch with expanded polytetrafluoroethylene suture was placed to reinforce the reconstructed commissure by approximating cusp remnants. A twisted pericardial strip was tightly anchored to the patched suture line of the mitral annulus and endocardium, and an annuloplasty ring was not used (Fig 1C). We mixed 500 mg of vancomycin and 5 mL of fibrin glue and applied it to the débrided cavity and pericardial strip.
Atriotomy closure, deairing, and decannulation were done in the standard manner. After the patient was weaned from the cardiopulmonary bypass, transesophageal echocardiography was used to assess the mitral valve function. In these 2 patients with commissural patch repair, intraoperative transesophageal echocardiography showed no regurgitation at the newly fashioned mitral valve.
Both patients made an uneventful postoperative recovery. They remain well at 10 months and 6 months of follow-up. Although the valve leaflets were resected surgically due to physiologic limitation and the mitral valve area was reduced to 2.0 and 1.8 cm2, respectively, no pressure gradient was detected. There was neither relapse of regurgitation nor reinfection of the mitral valve after operation.
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Comment
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Mitral valve repair has been considered as the preferred treatment of degenerative mitral regurgitation, and this has been confirmed by its resulting durability and by the minimal risk of failure and reoperation. In mitral valve endocarditis, valve replacement has remained the standard therapeutic approach for many years. Attempts have been undertaken to repair mitral endocarditis, however, and recent clinical studies suggest that mitral valve repair is associated with excellent early and late results, even in patients with active endocarditis [1, 2]. A recent systematic literature review showed that valve repair was performed in 312 of 875 patients (36%) with active endocarditis, and 158 of 319 patients (50%) with healed endocarditis. The rate of late recurrent endocarditis was significantly lower after mitral repair compared with mitral valve replacement (1.8% vs 7.3%, p = 0.0013) [3].
Not all patients are candidates for mitral valve repair because of varying extent of mitral valve tissue destruction, including adhesion of vegetation on leaflets. Moreover, in active endocarditis, including the presence of annular abscess, it requires complete resection of all pathologic tissues to prevent recurrent endocarditis, and the mitral valve repair becomes more complex and difficult. The damaged mitral annulus can be reconstructed with autologous pericardium. Valve resection is usually extensive, however, and there is no choice except mitral valve replacement [4]. Our commissural patch repair is a technique that enables mitral repair for such extensively destructive endocarditis.
The principle for surgical treatment of endocarditis is adequate excision of all infected tissue. We think that the repair could be accomplished with up to 50% excision of the valve area to apply the commissural patch repair. We preferred patch repair with glutaraldehyde-treated autologous pericardium because of its availability, durability, and resistance to infection [5]. The use of an antibiotic fibrin compound is a useful prophylactic tool to prevent postoperative residual endocarditis [6]. The annular reinforcement with autologous pericardium was limited to along the annular suture line. The aim is to prevent excess tension to the suture line from leakage rather than for the purposes of remodeling the annulus. It is important to minimize the insertion of foreign material, and because the repair was satisfactory, there was no indication for an additional annuloplasty ring.
In conclusion, commissural patch repair is a simple and beneficial procedure, especially in patients who require extensive resection in the commissural area involving both leaflets and mitral annulus. This novel repair technique should be considered as a standard method for complicated mitral endocarditis.
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References
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- Ruttmann E, Legit C, Poelzl G, Speier R, 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]
- de Kerchove L, Vanoverschelde JL, Poncelet A, et al. Reconstructive surgery in active mitral valve endocarditis: feasibility, safety and durability Eur J Cardiothorac Surg 2007;31:592-599.[Abstract/Free Full Text]
- Feringa HH, Shaw LJ, Poldermans D, et al. Mitral valve repair and replacement in endocarditis: a systematic review of literature Ann Thorac Surg 2007;83:564-570.[Abstract/Free Full Text]
- David TE, Feindel CM. Reconstruction of the mitral anulus Circulation 1987;76(suppl III):III102-III107.[Medline]
- Ng CK, Nesser J, Punzengruber C, et al. Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology Ann Thorac Surg 2001;71:78-85.[Abstract/Free Full Text]
- Watanabe G, Haverich A, Speier R, et al. Surgical treatment of active infective endocarditis with paravalvular involvement J Thorac Cardiovasc Surg 1994;107:171-177.[Abstract/Free Full Text]
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Abstract
Introduction
