Eur J Cardiothorac Surg 2004;26:837-838
© 2004 Elsevier Science NL
Mitral valve replacement after application of atrial appendix flap in endocarditis with posterior annular abscess
R
za Turkoza,
Oner Gulcana,*,
Emrah Uguza,
Hasan Berat Cihanb
a Department of Cardiovascular Surgery, Baskent Universitesi, Adana, Turkey
b Department of Cardiovascular Surgery, Inonu University, Malatya, Turkey
Received 18 April 2004;
received in revised form 26 June 2004;
accepted 13 July 2004.
* Corresponding author. Tp Fakültesi, Adana Uygulama ve Arastrma Hastanesi, Dadalo
lu mah. 39 sok. No: 6, PK: 01250 Adana, Turkey. Fax:+90-322-327-1273. (E-mail: drgulcan{at}yahoo.com).
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Abstract
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In patients with acute bacterial endocarditis and annular abscess formation, cardiac valve replacement is associated with high perioperative mortality and morbidity. We present two patients who had had infective endocarditis and annular abscess formation in the mural leaflet region. Before replacing the mitral valve, we covered the atrium and annulus with a flap of evaginated left atrial appendix.
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1. Introduction
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Mitral valve replacement in patients with active infection is associated with higher mortality and significant risk of recurrence, particularly in cases of perivalvular abscess.
In this report, we present two patients who had had infective endocarditis and annular abscess formation in the mural leaflet region, as well as spread of infection to the left atrium. Before replacing the mitral valve, we covered the atrium and annulus with a flap of evaginated left atrial appendix.
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2. Technique
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In both cases, vegetations were found on the posterior leaflet (Fig. 1A). In each case, all mitral valve structures were removed, the abscess in the posterior annulus and the infected portion of atrium were debrided aggressively, and all operated sites were cleaned with povidone-iodine. Next, the left atrial appendix was protruded into the left atrium. Then the neck (ostium) of the evaginated appendix was closed with a purse-string suture of 3-0 polypropylene (Fig. 1B). Care was taken to make this suture line tight enough to close the ostium completely but not to interrupt the blood supply to the appendix tissue. A straight incision was then made in the posterior part of the appendix tissue parallel to the suture line. The incision was extended near the lateral limits of the appendix. At both lateral edges, the incision was extended towards the apex of the appendix. This U-shaped incision thus formed a flap of left atrial appendix tissue with its base near the posterior annulus of the mitral valve. The flap was then flipped back at its base such that it extended toward the annulus and covered the site where the abscess had been removed. The flap was fixed in place with continuous 3-0 polypropylene sutures (Fig. 2A). After this re-construction, a bileaflet mechanical prosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) was inserted and fixed in place with interrupted sutures (Fig. 2B). The patients received 6 weeks of post-operative parenteral antibiotic therapy. Both were still doing well at 16 and 38 months of follow-up, respectively.
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Fig. 1. (A) An artist's rendering of the mitral valve as viewed through the left atrium, with bacterial vegetations on the posterior leaflet. (B) All mitral valve structures were excised, the abscess in the posterior annulus and the infected portion of the atrium were debrided aggressively. Then the left atrial appendix was gently maneuvered into the left atrium and the ostium was closed with a purse-string suture.
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Fig. 2. (A) After the left atrial appendix flap was created, it was manipulated so that it covered the thin, weakened portion of the mitral annulus. The edges of the flap were fixed. (B) Once the flap was secure, the prosthetic bileaflet mechanical valve was inserted and fixed in place with interrupted sutures.
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3. Comment
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We performed this technique successfully in two patients who presented with active infective mitral endocarditis with accompanying ring abscess. In patients with acute bacterial endocarditis, cardiac valve replacement is associated with high perioperative mortality (reported rates 11.5–31%), and increased risks of post-operative perivalvular leakage and re-infection of the prosthetic valve [1–3].
Annular and para-annular abscesses are rare in mitral valve endocarditis (14%), but are common in aortic valve endocarditis (52%) [4]. Compared to aortic valve abscesses, mitral abscesses are more likely to fistulate or form a pseudoaneurysm [4]. If the infection is limited to the mitral valve leaflets or the chordae tendinae, the infected areas can be totally removed and the valve prosthesis can be inserted into a sterile site. However, if a valve ring abscess is present, the infection may persist at the site of prosthesis attachment, or there may be significant paravalvular leakage after valve replacement.
Abscesses of the posterior mitral annulus are difficult to manage due to the proximity of the circumflex coronary artery, the coronary sinus, and the free wall of the ventricle. In these complicated cases, some authors have proposed re-construction of the mitral annulus with pericardium (fresh autologous or glutaraldehyde-fixed bovine pericardium), followed by mitral valve replacement [5]. The alternative technique is intra-atrial implantation of a mitral prosthesis by placing a dacron cloth collar at a non-infected site [6].
We believe that our appendix flap technique enhances healing because of the viability of the flap tissue. There are two main considerations with this technique: First, it is important that the purse-string suture be tight enough to prevent oozing of blood but loose enough to keep the pedicle viable. Second, the incision made parallel to the ostium must be as short as possible to ensure a wide pedicle. In patients with underlying mitral valve disease, the appendix is large enough to extend such a flap to the annulus. In addition to its application in active mitral valve endocarditis, this technique can also be used to re-construct perforations of the atrioventricular groove, a potentially fatal complication after mitral valve replacement.
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References
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- Lee EM, Shapiro LM, Wells FC. Conservative operation for infective endocarditis of the mitral valve. Ann Thorac Surg 1998;65:1087-1092.[Abstract/Free Full Text]
- Lewis BS, Agathangelou NE, Colsen PR, Antunes M, Kinsley RH. Cardiac operation during active infective endocarditis: results of aortic, mitral, and double valve replacement in 94 patients. J Thorac Cardiovasc Surg 1982;84:579-584.[Abstract]
- Bauernschmitt R, Jakob HG, Vahl CF, Lange R, Hagl S. Operation for infective endocarditis: results after implantation of mechanical valves. Ann Thorac Surg 1998;65:359-364.[Abstract/Free Full Text]
- Baumgartner FJ, Omari BO, Robertson JM, Nelson RJ, Pandya A, Pandya A, Milliken JC. Annular abscesses in surgical endocarditis: anatomic, clinical, and operative features. Ann Thorac Surg 2000;70:442-447.[Abstract/Free Full Text]
- d'Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of operation for paravalvular abscess. Ann Thorac Surg 1996;62:48-53.[Abstract/Free Full Text]
- Nataf P, Jault F, Dorent R, Vaissier E, Bors V, Pavie A, Cabrol C, Gandjbakhch I. Extra-annular procedures in the surgical management of prosthetic valve endocarditis. Eur Heart J 1995(16):99-102.
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Abstract
1. Introduction
