Complex Mitral Valve Repair in a 2-Year-Old Child With Severe Infective Endocarditis

Repair of the mitral valve which is partly destructed by an infective process is a big challenge in infants and small children. This is mainly because of the delicate nature of the mitral structure in this age group, and also limitations to use artificial chords and annuloplasty rings. However, complex repair is usually the only option in infants and small children and may achieve a satisfactory result (1). 

The authors present a 2-year-old patient who developed severe mitral valve endocarditis one month after percutaneous intervention for aortic coarctation. The infection did not respond to 1.5 months of antibiotic therapy and progression of the disease led to congestive heart failure and cardiogenic shock. He was transferred to the authors’ center for surgery. Echocardiography revealed severe mitral valve endocarditis with huge vegetations and multiple jet mitral regurgitation. Both mitral valve leaflets were involved but the anterior leaflet was especially destructed. The mitral annular diameter was 15 mm.

Due to the critical condition, an emergency operation was performed. The operative finding was multiple-site involvement of the mitral valve. The A1 and anterior commissure area was completely destructed and perforated. The infective process was extended to the mitral annulus, aortomitral continuity, and part of the free left atrial wall and left ventricular outflow tract. The area of the A3 and posterior commissure was also involved and destructed, but the damage was limited to the leaflet and its chords. Multiple smaller vegetations could be seen on p1 and p2. All the infected tissue had to be excised completely to be able to eradicate the infective process. In the A1-anterior commissure, debridement of infected tissue led to a large defect in the leaflet as well as the atrial wall, annulus, and the aortomitral fibrous continuity. The repair in this area was performed by two separate Matrix (Auto Tissue Berlin GmbH) equine pericardial patches positioned perpendicular to each other. The first patch was used to restore the cardiac wall. This patch was sutured from the aortic annulus all the way to the left atrial free wall. A semicircular line in the middle of this patch was marked as the expected location of the new annulus. Then the defect in the anterior leaflet and commissure was repaired by the second piece of patch, which was then sutured to the hypothetically marked annular line in the first patch. The area of A3-posterior commissure was then approached by excising the infected tissue with free margin, followed by closing the gap by another Matrix patch and transfer of secondary chords to the edge of the patch to support the new leaflet margin. The smaller posterior leaflet vegetations were excised and simply repaired. The water test confirmed perfect valve function with good coaptation. No annuloplasty ring was used. 

Echocardiography after the operation showed no mitral regurgitation or stenosis. The patient had dramatic improvement in condition and did very well after the operation. He has been regularly followed and the echocardiography 2.5 years after the operation showed no mitral regurgitation and only mild mitral valve stenosis with a mean gradient of 5 mm Hg. 

Complex repair of mitral valve is possible in most cases of severe endocarditis. All the efforts should be made to repair these valves, preferably with avoidance of artificial material as much as possible. The result and the expected durability of the repair may then be promising.

Reference

1. Walter EMD, Musci M, Nagdyman N, Hübler M,  Berger F, Hetzer R. Mitral valve repair for infective endocarditis in children. Ann Thorac Surg. 2007;84:2059-2065.

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