Transposition of the Anterior Mitral Leaflet as a Patch for Posterior Annular Abscess and MAC Debridement

Management of severe posterior mitral annular calcification or posterior deep abscess can be challenging and carries significant risk. The use of the anterior mitral valve leaflet as a posterior annular patch was first reported in 1996, and the five reports since have lacked intraoperative color images. The objective of this article is to show this technique with intraoperative images and a video in a case of an abscessed posterior mitral annular calcium that was patched with transposition of the anterior leaflet.



A sixty-four-year-old male patient presented with bacteremia, a worsening murmur, dyspnea, and multiple small focal embolic strokes from an infected traumatic foot ulcer. Echocardiography confirmed severe mitral and tricuspid valve regurgitation with a mitral vegetation. An endoscopic mitral valve replacement and tricuspid repair were performed with femoral arterial and venous cannulation. 

First, the patient’s heart was arrested with antegrade del Nido cardioplegia. The team found destruction of the P2 segment with an annular abscess complicating the posterior mitral annular calcification. All infected tissue was resected and debrided, leaving two large areas of bare posterior ventricular muscle. The anterior mitral leaflet was then resected from the annulus and transposed posteriorly in two segments and sewn as a patch. The annular valve sutures were placed on the patch, and a bioprosthesis was implanted. The tricuspid valve was then repaired with a beating heart.

The patient made a full recovery and was discharged home on postoperative day ten with full neurologic recovery. A predischarge echocardiogram showed no paravalvular leaks and no mitral or tricuspid valve regurgitation. At a ninety-day follow-up the patient was doing well, and echocardiogram showed no paravalvular leak with normal ventricular function. 

This case shows that use of the anterior mitral valve leaflet to patch the post mitral annulus helps preserve the ventricular to annular continuity and avoids the need for foreign material. Complicated posterior mitral annular debridement for MAC or endocarditis can be managed successfully with posterior transposition of the anterior mitral leaflet through a minimally invasive approach.

References

1. Smedira, Nicholas G. "Mitral valve replacement with a calcified annulus." Operative Techniques in Thoracic and Cardiovascular Surgery 8.1 (2003): 2-13.
2. Goksel, Onur, et al. "Mitral valve replacement with bileaflet preservation for complex annular calcification." Heart Surgery Forum. Vol. 11. No. 1. 2008.
3. Nezic, Dusko, et al. "Mitral valve replacement with posterior transposition of the anterior mitral leaflet which covers and buttresses partially decalcified posterior mitral annular bed." European journal of cardio-thoracic surgery 41.5 (2012): 1129-1131.

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