Partial posterior leaflet resection for mitral valve endocarditis and valve repair with autologous pericardium | |
DOI: 10.5606/e-cvsi.2022.1342 | |
Mehmet Ali Şahin, Erkan Kuralay | |
Department of Cardiovascular Surgery, A Life Hospital, Ankara, Türkiye | |
Keywords: Autologous pericardium, mitral endocarditis, valve repair | |
Herein, we present a 55-year-old female who underwent a mitral valve repair procedure for mitral valve endocarditis. Multiple vegetations
and leaflet tissues were surgically removed from the P1 and P2 scallops. The defect of the posterior leaflet was repaired using autologous
pericardium. Rims of the pericardium supported three artificial chordae to obtain good mitral coaptation. The postoperative course was
uneventful. The patient was discharged on the 30th postoperative day. |
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Mitral valve endocarditis (MVE) is defined as
the infection of the entirety or portion of one or
both mitral valve leaflets. Age, shock, prosthetic
valve endocarditis, reduced left ventricular function
(ejection fraction <40%), and recurrent endocarditis
are considered significant predictors of mortality.
However, current evidence regarding the treatment
and management strategy of MVE is not univocal
and often based on personal experiences.[1] The timing
and indications for surgical intervention to prevent
systemic embolism in infective endocarditis remain
controversial.[2] The rate of stroke is significantly higher
during the first two weeks of antibiotic therapy and in
those with left-sided infective endocarditis, particularly
in the mitral position. The early involvement of an
experienced cardiac surgeon is essential to determine
the optimal surgical option and timing to provide
the best outcome for patients with MVE. Surgical
techniques are also controversial. Mitral valve repair
can provide better long-and short-term survival.[3]
The feasibility of valve repair depends on the extent
of tissue destruction. If only one leaflet or scallop is
involved, conservative surgery is possible. Herein, we
report a case of posterior mitral leaflet endocarditis
located on P2 and P1 scallops. |
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CASE PRESANTATION
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A 55-year-old female patient was admitted to
our department with a high fever, fatigue, and dyspnea. Coxiella burnetii was yielded from repeated
blood cultures. Multiple large (>10 mm) vegetations
were found on the posterior mitral leaflet with
moderate mitral regurgitation at transesophageal
echocardiography (Figure 1a). Tetracycline 500 mg
two times daily and vancomycin 2 g daily were
administered. Surgical intervention was scheduled
for two days later. Ascending aorta and bicaval
cannulations were done. A superior septal approach
was used for mitral valve exposure. Multiple large
vegetations were found on the mitral P1 and P2
scallops (Figure 2a). Vegetations firmly adhered to
the posterior leaflet. The P1 and P2 scallops were
destructed during the removal of vegetations. Only
the P3 segment of the posterior leaflet was free of
endocarditis. The P1 and P2 scallops and the adhered
chordae were resected. All infected tissues were
removed (Figure 2b). The autologous pericardium
was processed with 0.001% glutaraldehyde.
Measurements were done on the debrided area, and
the autologous pericardium was tailored slightly
higher than those measurements. The pericardium was sutured to both the P3 scallop and the mitral
annulus of the P1 and P2 scallops (Figure 3). Three
artificial chordae were implanted on the sutured
pericardium. Satisfactory coaptation was obtained
by the saline test. A size 32 rigid ring was used for
annular stabilization. The cross-clamp time and total
perfusion time were 91 and 124 min, respectively.
Mild degree mitral regurgitation was found at the early postoperative transesophageal echocardiograph
examination (Figure 1b, Video 1). The postoperative
course was uneventful. Vancomycin administration
ceased at the end of the fourth postoperative week.
The patient was discharged on the 30th postoperative
day. Tetracycline therapy was extended to six weeks.
The general condition of the patient was good, and
the functional capacity was class I. |
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The clinical presentation of C. burnetii infections
(chronic Q fever) is insidious and lacks many of the
typical features of subacute bacterial endocarditis.
As a result, there is often a significant delay in
diagnosis. Despite increasing awareness, recent studies
demonstrate a mean delay of seven months from
symptom onset to diagnosis. The majority of cases
present with congestive heart failure due to valvular
dysfunction. Unlike typical cases of endocarditis,
fever is absent in a significant proportion and is
frequently intermittent or low grade. Although embolic
phenomena have been reported in up to one-third of
cases, these are usually limited to advanced disease.[1,4]
The incidence of infective endocarditis in the general
population has ranged from 16 to 62 cases per
million person-years.[4] Despite advances in diagnostic
techniques and therapeutic strategies, infective
endocarditis remains associated with substantial
morbidity and mortality, with overall mortality
rates for native and prosthetic valve endocarditis
as high as 20 to 25%.[1-3] The timing of surgery is
crucial for patients with native valve endocarditis.
Delaying surgery often increases both the probability
of complications (stroke/systemic embolization) and operative mortality. Unfortunately, most surgeons
find that cardiologists or other hospitals refer patients
with infective endocarditis after the failure of medical
therapy, when patients are in intractable heart failure,
or when patients have experienced extensive heart
tissue damage. In a systematic review of the literature
evaluating the morbidity and mortality of mitral
valve repair compared to replacement in infective
endocarditis, the repair group showed a significantly
lower in-hospital mortality (2.3% vs. 14.4%) and a
markedly better 10-year survival rate compared to
the replacement group (long-term mortality, 7.8% vs.
40.5%).[3] Similarly, another review of the literature
demonstrated better long-term event-free survival.[5,6]
The goals of mitral valve repair are to remove the
vegetation while restoring a proper line of coaptation
on both leaflets to repair the leaflet if perforated and
preserve the subvalvular apparatus. Excision of the
vegetation can be performed along its cleavage plane
on the leaflet. En bloc removal of the infective tissue is
needed when the infection extends to the leaflet tissue.
Extensive removal creates a large leaflet tissue defect.
We have used glutaraldehyde-processed autologous
pericardium to repair the P1 and P2 area. Three
PTFE (polytetrafluorethylene) artificial chordae
sutures were placed to obtain satisfactory coaptation.
Nonbiological material usage is still controversial in
endocarditis surgery. Nonetheless, recently published
studies advocate that prosthetic materials can be used after an adequate debridement procedure.[6] We used a
rigid prosthetic ring as we were sure that all infected
tissues were completely removed. In conclusion, the primary objective of valve endocarditis surgery is to start surgery before the development of an embolic process and remove all necrotic tissues and continue sufficient antibiotic therapy in the postoperative period. Patient Consent for Publication: A written informed consent was obtained from the patient. Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request. Author Contributions: All authors contributed equally to the article. Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article. Funding: The authors received no financial support for the research and/or authorship of this article. |
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1) Nappi F, Spadaccio C, Dreyfus J, Attias D, Acar C, Bando
K. Mitral endocarditis: A new management framework. J
Thorac Cardiovasc Surg 2018;156:1486-95.e4.
2) Kang DH, Kim YJ, Kim SH, Sun BJ, Kim DH, Yun SC,
et al. Early surgery versus conventional treatment for
infective endocarditis. N Engl J Med 2012;366:2466-73.
3) Feringa HH, Shaw LJ, Poldermans D, Hoeks S, van der Wall
EE, Dion RA, et al. Mitral valve repair and replacement in
endocarditis: A systematic review of literature. Ann Thorac
Surg 2007;83:564-70.
4) Hogevik H, Olaison L, Andersson R, Lindberg J, Alestig
K. Epidemiologic aspects of infective endocarditis in an
urban population. A 5-year prospective study. Medicine
(Baltimore) 1995;74:324-39.
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