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Letters to the Editor |
Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
Received 3 November 2008; accepted 4 November 2008.
* Corresponding author. Address: 66 Ada, Kardelen 3/3, No: 42, Atasehir 34758, Kadikoy, Istanbul, Turkey. Tel.: +90 216 4556800; fax: +90 216 3379719. (Email: onursokullu{at}gmail.com).
Key Words: Posterior ventricular rupture • Calcified annulus • Infective endocarditis • Emergency
We would like to thank Dr Sersar et al. [1] for their interest and comments about our article. It is good to see that our colleagues agree with us about the risk factors for posterior ventricular rupture (PVR) mentioned in our study.
We are also interested in the case which was reported in their letter. Although we did not experience a complication related to malpositioning of the prosthesis, it seems to be reasonable and excessive preservation should be avoided. Integrity of the mitral subvalvular apparatus is very important in mitral valve surgery. Hosono et al. stated that preservation of the basal chordae of the posterior leaflet was important to prevent PVR [2]. Proper preservation of the leaflet may also represent the preservation of the chordae and the papillary muscles, and this may result with a well protected left ventricular geometry.
Papillary muscle excision and extreme traction applied on the calcified mitral annulus were thought to be the causes of PVR. When extreme annular calcification was observed during the operation, complete resection of the valve and implantation of the prosthesis were performed with gentle and careful manipulations. Excessive decalcification was avoided in patients with less annular calcification. This strategy may result with less complications during and after the surgery, especially PVR.
The appropriate surgical management for native and prosthetic valve endocarditis is still controversial. Although success with valvular repair was reported, valve replacement remains to be the gold standard management for active endocarditis. Abscess debridement followed by autologous or bovine pericardial patch, or Dacron annular reconstruction may be needed additionally. Ishikawa et al. stated that operative results of native valve endocarditis were good after complete resection of infective sites including the valve annulus [3]. In our patients with endocarditis, the infective tissue was excised carefully, the native valve was resected and a prosthetic valve was implanted. In 87 patients, we did not experience any PVRs.
Emergency surgery is generally indicated in patients with acute severe mitral regurgitation. Although degenerative mitral valve disease and infective endocarditis contribute to its occurrence, this clinical condition is mostly related to mitral valve dysfunction as a result of acute myocardial infarction [4]. A new study by Lorusso et al. demonstrated that the type of surgical correction, either repair or replacement (preserving or not the valve leaflets), did not provide any beneficial effect at short- or long-term postoperatively [5]. The high rate of mortality (22.5%) was related to the presence of cardiogenic shock, left ventricular dysfunction, coronary artery disease and endocarditis [5]. Unlike the degenerative and rheumatic mitral valves, the structure of the valvular apparatus is well protected in these patients and leaflet preservation may generally be performed. This may result with a low incidence of PVR. In our series, we did not see any PVRs.
References
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