AVNeo™ (Ozaki) and Transaortic Mitral Valve Repair Using Autologous Pericardium Only for Aortomitral Endocarditis

Aortomitral valve infective endocarditis (IE) is a very challenging clinical condition (1). The author presents a case of aortomitral valve IE treated with a total biological solution by combining the Aortic Valve Neocuspidalization Ozaki procedure (AVNeo™) (2) and mitral valve repair with exclusive use of autologous pericardium through a total transaortic approach. While mitral valve repair with autologous pericardium is a well-recognized strategy for patients with mitral IE (3), AVNeo™ has been reported primarily in patients with degenerative aortic valve disease (2). The use of AVNeo™ in aortomitral valve IE represents a very attractive strategy as it extends the use of autologous pericardium not only for mitral valve repair, but also for the treatment of the the aortic valve.

Case report
A 50-year-old man was admitted with malaise, pyrexia, and a new murmur and no other pre-existing comorbidities. A transthoracic echocardiogram (TTE) showed trileaflet AV endocarditis with severe aortic valve insufficiency and a perforation of the anterior mitral valve leaflet with severe mitral regurgitation, and a decision for emergency surgery was made. Surgical steps included aortotomy and aortic valve leaflets resection; extension of the aortotomy into the noncoronary aortic annulus to provide good exposure of the anterior mitral valve leaflet using two 5-0 prolene sutures placed through healthy mitral valve chords to lift it up. The anterior mitral valve leaflet was excised almost entirely except for the edge of the anterior mitral leaflet, where marginal chordae (primary chordae) were inserted. A patch of autologous pericardium was trimmed to size and used to repair the anterior mitral valve leaflet with 4/0 Prolene running sutures. The superior edge of the mitral patch was extended into the noncoronary sinus to reinforce the mitro-aorto continuity. AVNeo™ with autolougous pericardium was performed using three size 31 leaflets implanted with three 4/0 Prolene running sutures. The patient was successfully weaned from CPB, and transesophageal echocardiogram showed no significant aortic or mitral regurgitation and low gradients across both valves. Streptococcus sanguinis was isolated by blood cultures and intraoperative specimens, and targeted antimicrobial therapy (Benzylpenicillin) was administrated for six weeks with complete resolution of the infection. Patient was discharged, and 6-month echocardiographic follow-up confirmed well-functioning mitral and aortic valves with no evidence of recurrent infection.

References

1. Navia JL, Elgharably H, Hakim AH, Witten JC, Haupt MJ, Germano E, et al. Long-term outcomes of surgery for invasive valvular endocarditis involving the aortomitral fibrosa. Ann Thorac Surg. 2019;108:1314-1323.
2. Ozaki S, Kawase I, Yamashita H, Uchida S, Takatoh M, Kiyohara N. Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg. 2018;155: 2379-2387.
3. Quinn RW1, Wang L2, Foster N2, Pasrija C2, Ghoreishi M2, Dawood M2, et al. Long-term performance of fresh autologous pericardium for mitral valve leaflet repair. Ann Thorac Surg. 2020 Jan;109(1):36-41.

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