Posterior Annulus Reinforcement with Autologous Pericardium During Mitral Valve Replacement for Endocarditis and Severe MAC

This video demonstrates the use of autologous pericardium to reinforce and reconstruct the posterior annulus during a mitral valve replacement for endocarditis and severe mitral annular calcification (MAC). 

Background 

The patient was initially admitted for pneumonia and sepsis. After persistently positive blood cultures despite appropriate antibiotics, he underwent an echocardiogram on hospital day four, which identified mitral valve endocarditis and mitral valve regurgitation. The remainder of the patient’s medical and surgical history was largely noncontributory. The patient’s preoperative evaluation involved a CT coronary angiography that did not demonstrate any significant coronary artery disease and a normal carotid ultrasound. A CT of the chest, abdomen, and pelvis was also performed, and it only demonstrated the known MAC. 

The Surgery 

Two small strips of pericardium were harvested immediately after the sternotomy and pericardotomy. Vegetations on the posterior leaflet were immediately apparent upon entering the left atrium. A large purulent fluid collection was encountered while debriding the posterior leaflet and annulus. This fluid was sent for Gram stain and culture to potentially help guide future antibiotic therapy. Then the remaining posterior leaflet was excised, along with another abscess cavity involving the calcified posterior annulus. All excised tissue was sent for pathologic evaluation and culture. 

Next, attention was turned to the calcified posterior annulus, which was debrided with a combination of scissors and a scalpel. After excision of all clearly infected tissues, the surgical field was irrigated with an antibiotic solution. 

Once all infected tissues were debrided and removed, along with a significant amount of the annular calcification, the annulus was reinforced and reconstructed with the two previously harvested strips of pericardium. One strip was placed on the ventricular side, and one strip was placed on the atrial side. Then the strips were secured in place with nonpledgeted interrupted Prolene sutures. 

Before sizing the new valve, the left atrial appendage was closed. On the anterior leaflet, a central segment was excised. The chordae, which appeared healthy, were preserved. The remaining tissue was taken with the valve stitches. An interrupted suture technique with pledgets was utilized for maximum strength and security. Posteriorly, the valve stitches were placed through both the atrial and ventricular pericardial strips on the reconstructed annulus. The new valve was sized at 29mm and sewn into place. 

The patient underwent transesophageal echocardiogram on the operating room table, which demonstrated no regurgitation, stenosis, or outflow tract obstruction. He was discharged after an uneventful recovery. A transthoracic echocardiogram prior to discharge was also unremarkable. 

Reference

1. Salvador L, Cavarretta E, Minniti G, Di Angelantonio E, Salandin V, Frati G, Polesel E, Valfrè C. Autologous pericardium annuloplasty: a "physiological" mitral valve repair. J Cardiovasc Surg (Torino). 2014 Dec;55(6):831-9. Epub 2014 Sep 30. PMID: 25268074.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.