Single Leaflet Neocuspidization for Aortic Regurgitation Due to Infective Endocarditis in Adult Congenital Heart Disease

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An 18-year-old female with a recent history of fever presented with chest pain, palpitations, and worsening dyspnea on exertion over the past month. She had been treated with a course of antibiotics one month earlier and was referred to the authors for further evaluation and management. Two-dimensional echocardiography suggested a moderate-sized perimembranous ventricular septal defect (VSD) restricted by right coronary cusp (RCC) prolapse, with a left-to-right shunt and severe aortic insufficiency and vegetations on the RCC. 

Surgical Technique  

The corrective surgery began with a midline sternotomy and moderately hypothermic cardiopulmonary bypass with aortic and bicaval cannulation. A moderate-sized perimembranous VSD was found to be restricted by prolapse of the RCC, which was thickened and tethered to the margin of VSD, with vegetations and calcification over its free edge. The NCC was mildly thickened with some vegetations but remained pliable, while the LCC was normal. The vegetations over the RCC and NCC were removed. The VSD was closed with a 0.4 mm expanded PTFE patch using a combination of interrupted and continuous sutures passed through the right atrium after the resection of a subaortic membrane and some hypertrophied right ventricular outflow tract muscle bundles. A careful examination of the cusp-annular complex, with the help of a Frater’s stitch, revealed noncoaptation of the NCC and RCC due to thickening and restricted mobility of the RCC. Consequently, the RCC was excised completely and reconstructed using the principle of the neocuspidization technique described by Ozaki et al., but for a single leaflet without using a template. 

Using an appropriate valve sizer, the aortic valve annulus was measured to be 25 mm. An additional 5 mm was added to achieve a good coaptation height and aid in the suturing of the neo-cusp.  A new leaflet, measuring 30 mm in both width and height, was constructed from 0.6 percent glutaraldehyde treated autologous pericardium and sutured to the respective part of the annulus with polypropylene sutures with the rough surface facing upward. Good coaptation was ensured, and the aortotomy was closed in two layers. 

Postoperative transesophageal echocardiography showed all three leaflets of the aortic valve moving well, with good coaptation and no aortic regurgitation. The postoperative course was uneventful. On follow-up, the patient was asymptomatic, with no residual lesions on echocardiography. 

Conclusion 

The aortic valve neocuspidization technique described by Professor Ozaki et al. is a trileaflet reconstruction in which templates are available to construct the new leaflets (1). Different techniques for trileaflet reconstruction have been described without the use of such templates (2).  

However, in this case, by applying the principle of neocuspidization and introducing a modification of the templateless technique, the authors have demonstrated that even a single leaflet neocuspidization can be performed to repair the aortic valve in patients with a destroyed leaflet due to infective endocarditis in adult congenital heart disease. This technique has the advantage of reconstructing an entire leaflet, providing good coaptation height while allowing the maximal preservation of native normal tissue in this subset of patients. For females of childbearing age, this technique also obviates the need for prosthetic valves and complications related to them. 

References

1. Ozaki S, Kawase I, Yamashita H, et al. Aortic valve reconstruction using self-developed aortic valve plasty system in aortic valve disease. Interact Cardiovasc Thorac Surg. 2011;12(4):550-553. doi:10.1510/icvts.2010.253682
2. Tambrallimath PR, Chatterjee S, Bose S. Aortic Valve Repair With All Cusp Replacement Using Treated Autologous Pericardium: The Ozaki Technique. August 2019. doi:10.25373/ctsnet.9589007.v1

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