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J Thorac Cardiovasc Surg 1994;107:1460-1463
© 1994 Mosby, Inc.
SURGERY FOR ACQUIRED HEART DISEASE |
Barcelona, Spain
From the Departments of Cardiovascular Surgery, a Cardiology, b and Infectious Diseases, c Hospital Clinico y Provincial, University of Barcelona, Barcelona, Spain.
Received for publication July 1, 1993. Accepted for publication Oct. 5, 1993 Address for reprints: Jose L. Pomar, MD, PhD, Cardiovascular Surgery, Hospital Clinico y Provincial, University of Barcelona, c/Villarroel 170, 08036 Barcelona, Spain.
Abstract
Transplantation of the human mitral valve in the tricuspid position for intractable infective endocarditis has been successfully performed in three young patients who were addicted to drugs. The maximum follow-up is 20 months. The rationale and historical basis for using this approach in the surgical treatment of patients with right-sided infective endocarditis is discussed and the appropriate literature reviewed. Because the technical aspects have been previously reported, this article can be considered an argument to renew past interest in atrioventricular valve replacement with fully biologic tissue of human origin. (J THORAC CARDIOVASC SURG 1994;107:1460-3)
Right-sided infective endocarditis is a serious clinical condition. Its social impact must be considered because of the high number of persons addicted to drugs who are being admitted to general hospitals for a variety of conditions. Inasmuch as right-sided infective endocarditis is mostly associated with intravenous drug abuse, many institutions are facing the problem of valve infections in this problematic group of patients.
At our institution, right-sided infective endocarditis is a common medical problem because a large population of persons who abuse intravenous drugs are being referred for medical care. Nowadays, right-sided infective endocarditis accounts for more than 50% of the cases of infective endocarditis managed by our department of infectious diseases. Even though medical treatment is usually effective and reliable, in a few of our cases uncontrollable bacterial or fungal infections of the tricuspid valve necessitated surgical treatment.
Few reports have dealt with the surgical management of right-sided infective endocarditis. Arbulu and associates
1-3 summarized the results of surgical treatment of life-threatening tricuspid valve infections over a 25-year period. They advocated tricuspid valve excision without valve replacement as a life-saving operation in patients who have uncontrollable infection and who also abuse intravenous drugs. Their idea was to avoid all the inconveniences of inserting a new prosthetic device in the tricuspid position, because reinfection is common among persons actively abusing intravenous drugs. Excellent results were obtained in control and eradication of valve infection. However, long-term follow-up showed that right-sided heart failure can appear as a consequence of chronic massive tricuspid regurgitation and, in some patients, late implantation of a valve prosthesis may be required. 1
We are presenting our early experience with a new approach. To avoid using any synthetic material, we transplanted a cryopreserved human mitral valve complex into the tricuspid position in three patients with right-sided infective endocarditis. Details of the surgical technique have been previously described elsewhere. 4 In all patients, mitral homografts procured, dissected, and preserved at our own valve bank facilities* were used to replace the infected tricuspid valve.
PATIENTS AND METHODS
Patients
Three patients underwent tricuspid valve replacement with a cryopreserved mitral homograft from our own valve bank. These homografts were procured through the Spanish Transplant Coordinators Network and sent to our valve bank for further processing. All three patients were actively abusing heroin, and results of enzyme-linked immunosorbent assay were positive for the human immunodeficiency virus. The patients had active right-sided infective endocarditis with massive tricuspid insufficiency and uncontrolled sepsis. Patient characteristics are shown in Table I. Surgical treatment for their tricuspid valve disease was indicated because of the inability to control infection.
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4 We would emphasize, however, that the papillary muscles of the donor valve are properly trimmed after tricuspid valvulectomy has been performed (Fig. 1). The donor muscles are sutured to the native tricuspid papillary muscles with fine Prolene sutures (Ethicon, Inc., Somerville, N. J.) supported with pledgets made of native pericardium. Another strip of native pericardium is used to cover the donor mitral anulus where muscle is visible before the homograft is finally sutured to the host tricuspid anulus. We used cardioplegic arrest, but we also believe that this operation can be performed at normothermia with the heart beating.
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All three patients survived and were discharged after completion of the antibiotic and antifungal therapy at different time intervals after the operation. They are currently in New York Heart Association class I. Follow-up has extended to 20 months. Transthoracic two-dimensional echocardiography with Doppler analysis and color-flow mapping was used to assess valve function. Two patients had trivial central regurgitation and one patient had moderate valve incompetence, probably because of redundant anterior and posterior leaflets prolapsing into the right atrial chamber. The first patient had a new episode of right-sided infective endocarditis during the follow-up period, because of persistent drug addiction. The endocarditis was successfully managed with antibiotics, and two-dimensional echocardiography showed no significant impairment in valve function and competence. Two patients are still addicted to drugs, but the third seems to have abandoned the habit.
DISCUSSION
The outcome in the three cases presented herein has been satisfactory in terms of achieving complete cure of the infection and reaching a certain degree of tricuspid competence. In addition, all patients returned to an active life and are in functional class I. Two of them continue to abuse drugs.
Semilunar valve replacement with homograft tissue is presently an accepted method of treatment in cases of congenital and acquired diseases of the left and right ventricular outflow tracts. The pioneering work of Duran and Gunning, 5 Ross, 6 and Barratt-Boyes 7 always must be considered in discussions of homografts in the aortic and pulmonary positions, because they established the fundamentals for our present knowledge of tissue transplants. The atrioventricular valve has usually been replaced with mechanical valves or xenobioprostheses. Both types of substitutes have specific advantages and disadvantages. Because the ideal substitute for atrioventricular valves is still to be designed, a variety of devices have been tested on an experimental and clinical basis with differing degrees of success. In addition, the mitral valve is a complex functional unit in which not only the anulus, leaflets, and chordae (with its papillary attachments) play a role, but also the atrial contraction and the left ventricular architecture.
Homograft tissue has been used in the past to replace diseased human mitral valves. 8,9 Because of the initial encouraging experience with homograft replacement of the aortic valve, some authors used stent-mounted aortic or pulmonary homograft valves in the mitral position. 8-10 However, the medium and long-term results were disappointing. This fact, together with the cumbersome preparation of the composite grafts, led to the abandonment of this type of mitral valve replacement, at least on a routine basis. 11,12 On the other hand, the idea of replacing the mitral valve with a homograft mitral valve is not new. 13,14 Poor clinical outcome resulted in the discontinuation of such clinical attempts. 15
With the present status of valve repair, more than 95% of diseased tricuspid valves can be repaired. 16,17 However, the right atrioventricular valve still has to be replaced in some cases. The treatment of this condition has evolved from replacement with a mechanical prosthesis, which is associated with an unacceptably high rate of thrombosis, 18 to the use of bioprostheses. Although McKay, Sons, and Arnold 19 used unstented pulmonary homografts for tricuspid valve replacement, we are not aware of previous reports concerning the use of a mitral homograft in this condition.
Infective endocarditis of the tricuspid valve is now common, especially at large referral tertiary institutions. Intravenous drug abuse currently is responsible for more than 50% of the cases of infective endocarditis seen at our hospital. However, because antibiotic therapy is able to control the infection in most cases, the indications for surgery are restricted to persistent sepsis and life-threatening septic pulmonary embolus; we do not believe that an isolated vegetation in itself is an indication for operation.
The reasons for using a mitral homograft for right atrioventricular valve replacement in patients with right-sided infective endocarditis were to achieve postoperative competence of the right atrioventricular orifice, to avoid the late development of right-sided heart failure, 3 and to avoid the use of any synthetic material in the setting of infection. Our short experience shows that tricuspid valve replacement with a mitral homograft is technically feasible. It allowed us to completely excise the infected tricuspid tissue in the cases described herein and to provide a significant degree of competence at the right atrioventricular orifice.
Postoperative follow-up of 20 months has shown good clinical results in all patients with different degrees of valve regurgitation, from trivial to a moderate degree of central leakage. However, this regurgitation remained stable from the beginning and consequently seems to be related to the surgical procedure more than to intrinsic dysfunction of the graft. Moreover, one patient recently had a new episode of right-sided infective endocarditis as a result of persistent addiction, but he responded well to antibiotic therapy and no further changes in valve hemodynamics were noticed with follow-up two-dimensional echocardiography.
As already pointed out by Cosgrove, 18 this new technique should be accompanied by a systematic and careful method for locating the proper point of implantation of the papillary muscles. Further studies on the mitral and tricuspid anatomy, their exact topography, and the relations among all their complex integrals are already being undertaken. This is the logical step to facilitate choosing the proper size and positioning of the graft.
In summary, tricuspid valve replacement with mitral homografts is a promising technique in selected cases of right-sided infective endocarditis. Long-term follow-up is obviously needed to ascertain clinical and hemodynamic results. The possibility of using this technique for other congenital or acquired conditions might also be explored. Because homograft tissue has been used satisfactorily in the aortic and pulmonary positions for a number of years, the question of renewing interest in atrioventricular valve replacement with homografts, including the mitral valve, is again open for discussion. 20 The recent report from Vrandecic and associates, 21 from Brazil, regarding replacement of the mitral valve with complete mitral heterografts is a stimulating experience that deserves careful consideration. Any additional experience in this field might be welcomed by the surgical community.
Acknowledgments
We thank Elba Agusti, biologist, and Anna Martinez, MD, for their cooperation in processing the homografts.
Footnotes
*Criobarna Valve Bank, Hospital Clínico, Barcelona, Spain. 
References
This article has been cited by other articles:
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  R. J. Shemin Tricuspid Valve Disease Card. Surg. Adult, January 1, 2008; 3(2008): 1111 - 1128. [Full Text]
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 M. G. Cardarelli, J. S. Gammie, J. M. Brown, R. S. Poston, R. N. Pierson III, and B. P. Griffith A Novel Approach to Tricuspid Valve Replacement: The Upside Down Stentless Aortic Bioprosthesis Ann. Thorac. Surg., August 1, 2005; 80(2): 507 - 510. [Abstract] [Full Text] [PDF]
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 A. Kalangos, J. Sierra, M. Beghetti, P. Trigo-Trindade, D. Vala, and J. Christenson Tricuspid valve replacement with a mitral homograft in children with rheumatic tricuspid valvulopathy J. Thorac. Cardiovasc. Surg., June 1, 2004; 127(6): 1682 - 1687. [Abstract] [Full Text] [PDF]
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R. J. Shemin Tricuspid Valve Disease Card. Surg. Adult, January 1, 2003; 2(2003): 1001 - 1015. [Full Text]
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J.-P. A. Couetil, P. G. Argyriadis, A. Shafy, A. Cohen, A. J. Berrebi, D. F. Loulmet, J.-C. Chachques, and A. F. Carpentier Partial replacement of the tricuspid valve by mitral homografts in acute endocarditis Ann. Thorac. Surg., June 1, 2002; 73(6): 1808 - 1812. [Abstract] [Full Text] [PDF]
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 J.M. Grinda, R. Zegdi, R. Leroux, and A. Deloche Tricuspid bioprosthesis replacement with cryopreserved mitral homograft Eur. J. Cardiothorac. Surg., April 1, 2002; 21(4): 763 - 764. [Abstract] [Full Text] [PDF]
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M. Murtra The adventure of cardiac surgery Eur. J. Cardiothorac. Surg., February 1, 2002; 21(2): 167 - 180. [Full Text] [PDF]
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U. Hvass, F. Baron, D. Fourchy, and Y. Pansard Mitral homografts for total tricuspid valve replacement: Comparison of two techniques J. Thorac. Cardiovasc. Surg., March 1, 2001; 121(3): 592 - 594. [Full Text] [PDF]
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J. M. Bernal, J. M. Rabasa, J. C. Cagigas, F. Val, and J. M. Revuelta Behavior of Mitral Allografts in the Tricuspid Position in the Growing Sheep Model Ann. Thorac. Surg., May 1, 1998; 65(5): 1326 - 1330. [Abstract] [Full Text] [PDF]
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A. Prat, O. H. Fabre, A. Vincentelli, V. Doisy, and G. Shaaban Ross Operation and Mitral Homograft for Aortic and Tricuspid Valve Endocarditis Ann. Thorac. Surg., May 1, 1998; 65(5): 1450 - 1452. [Abstract] [Full Text] [PDF]
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R. Bauernschmitt, H. G. Jakob, C.-F. Vahl, R. Lange, and S. Hagl Operation for Infective Endocarditis: Results After Implantation of Mechanical Valves Ann. Thorac. Surg., February 1, 1998; 65(2): 359 - 364. [Abstract] [Full Text] [PDF]
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 S. F. Aranki, D. H. Adams, R. J. Rizzo, G. S. Couper, T. E. Sullivan, J. J. Collins Jr, and L. H. Cohn Determinants of Early Mortality and Late Survival in Mitral Valve Endocarditis Circulation, November 1, 1995; 92(9): 143 - 149. [Abstract] [Full Text]
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