Ann Thorac Surg 2009;88:1708-1709. doi:10.1016/j.athoracsur.2009.02.041
© 2009 The Society of Thoracic Surgeons
How To Do It
Double-Valve Endocarditis Homograft and Patch Repair
Morteza Tavakkoli Hosseini, MD,
Antonios Kourliouros, MRCS,
Mazin Sarsam, FRCS, EBCTS*
Department of Cardiothoracic Surgery, St. Georges Hospital, London, United Kingdom
Accepted for publication February 18, 2009.
* Address correspondence to Dr Sarsam, Department of Cardiothoracic Surgery, St. Georges Hospital, BlackShaw Rd, London, SW17 0QT, United Kingdom; (Email: mazin.sarsam{at}stgeorges.nhs.uk).
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Abstract
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We present our technique for reconstruction of aortic valve, mitral valve, and aortomitral curtain in double-valve endocarditis with involvement of intervalvular fibrous body.
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Introduction
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Infective endocarditis may represent a surgical challenge when the process extends beyond the valve leaflets and destroys the annulus and the surrounding structures with fistula and abscess formation. In the case of both aortic and mitral valves, the infective process can spread through fibrous skeleton, involving the aortomitral curtain. Large abscess cavities can completely disrupt the aortomitral continuity, involving the roof of the left atrium, anterior leaflet of mitral valve, aortic valve and annulus, ventricular infundibular septum, and a portion of the interatrial septum through to the tricuspid valve [1].
Extension of infection below the aortic valve is a serious complication, especially with involvement of the mitral apparatus. Mortality is substantial and reinfection can strongly influence the outcome. Reconstruction of the intervalvular fibrous body is a technically challenging operation, but it is indicated for patients with complex valve pathology for whom no alternative procedure is available [2]. Studies have shown that reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement is a satisfactory operative approach to take in patients who have complex valve pathology.
The aortic and the mitral valves are connected with a fibrous body that extends from the lateral to the medial trigones. The fibrous structure is seldom more than 1 cm in height and from the ventricular side it is indistinguishable from the anterior leaflet of mitral valve, until the point where the non coronary cusp of aortic valve begins. From the atrial side, the dome of the left atrium is attached to it, separating the anterior leaflet of the mitral valve from the aortic root. The fibrous body may be damaged by infective endocarditis, degenerative calcification, or previous mitral valve replacement, making combined aortic and mitral valve replacement difficult [3].
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Technique
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Homograft replacement of aortic valve in case of acute bacterial endocarditis is considered the ideal choice because of the resistance of the homograft to reinfection [4]. A transverse aortotomy was performed followed by excision of the infected aortic valve, dissection of the coronary artery buttons, excision of the aortic root, and resection of all the infected tissue surrounding the aortic root. A second incision starting on the left atrial dome at the level of the superior vena cava was directed toward the aortic incision up to the level of the annulus. Radical debridement was undertaken depending on the extent of the tissue destruction. The debridement could include the entire aortomitral curtain, left atrial dome, anterior mitral leaflet, or the whole mitral valve.
We used bovine pericardial patch to reconstruct the aortomitral continuity and to close the left atrial dome. We used one patch (trimmed into an oval shape) to reconstruct the aortomitral continuity and the dome of the left atrium, instead of using two separate patches. A rectangular bovine pericardial patch was used to reinforce the annular suture line for the aortic homograft (Fig 1). The patch technique also allows the surgeon to enlarge both annuli and insert a valve prosthesis that is at least two sizes larger than the native annuli [5].
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Fig 1. Bovine pericardial patch. (A) Oval-shaped patch. (B) Rectangular patch for reinforcement of aortic annulus. (C) Triangular patch for covering the left atrial dome. (D) Patch for mitral valve replacement. (E) Patch for mitral valve repair.
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If the mitral valve involvement was only restricted to the anterior leaflet, the anterior leaflet of the homograft or part of the bovine pericardial patch was used for repairing the original anterior leaflet of the mitral valve (Fig 2). If the mitral valve involvement was extensive, the whole mitral valve would be excised, and it would be replaced by a prosthetic valve (Fig 3). The aortic root was replaced by a homograft, with reimplantation of coronary buttons.
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Fig 2. Posterosuperior view of the left atrium. (A) Aortic homograft and repair of anterior leaflet of native mitral using the homograft leaflet. (B) Repair of anterior leaflet of native mitral using the bovine pericardial patch. (C) Left atrial dome closed with the bovine pericardial patch.
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Fig 3. Mitral valve replacement. (A) Posterosuperior view of the left atrium. (B) Coronal view of mitral valve prosthesis, pericardial patch, and aortic homograft.
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Comment
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This technique has proved to be practical and reproducible with good short-term and long-term results. We successfully performed this technique in 6 suitable patients between 2003 and 2008. During the maximum follow-up of 4 years, there has been 1 case of stroke and 1 death due to unresolved sepsis on the 26th postoperative day of a redo operation for early prosthetic valve bacterial endocarditis. Echocardiographic assessment during follow-up has revealed only trivial to mild mitral regurgitation, with the exception of 1 case of moderate mitral regurgitation, which is under regular echocardiographic surveillance. There has been no evidence of late homograft reinfection so far.
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References
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- Kalra PR, Tang AT, Morgan JM, Haw MP. Complex and extensive infective endocarditis: a novel surgical approach Eur J Cardiothorac Surg 2002;21:365-368.[Abstract/Free Full Text]
- De Oliveira NC, David TE, Armstrong S, Ivanov J. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes J Thorac Cardiovasc Surg 2005;129:286-290.[Abstract/Free Full Text]
- David TE, Kuo J, Armstrong S. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body J Thorac Cardiovasc Surg 1997;114:766-772.[Abstract/Free Full Text]
- Amado-Cattaneo R. Combined mitral and aortic homograft valve replacement for acute bacterial endocarditis Ann Thorac Surg 1998;66:267-268.[Abstract/Free Full Text]
- Bauset R, Dagenais F. Double valve replacement through an aorto-annulo-atriotomy using an aortic-valved graft in a mitral position Ann Thorac Surg 2002;73:1986-1987.[Abstract/Free Full Text]
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Y. G. Peng, T. D. Martin, and G. M. Janelle
Reply.
Ann. Thorac. Surg.,
October 1, 2010;
90(4):
1396 - 1396.
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Abstract
Introduction
