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J Thorac Cardiovasc Surg 2006;131:243-245
© 2006 The American Association for Thoracic Surgery

Brief Communication

Monobloc aorto-mitral homograft or mechanical valve replacement: A new surgical option for extensive bivalvular endocarditis

^a INSERM, Service de Chirurgie Cardiothoracique et Transplantation (Cardiothoracic Surgery and Transplant Department), Hôpital Cardiothoracique Louis Pradel
^b Service de Cardiologie (Cardiology Department), Hôpital Cardiothoracique Louis Pradel, Lyon-Bron
^c Centre Cardiologique du Nord, Saint Denis Cedix, France

Received for publication May 18, 2005; accepted for publication May 26, 2005.

^_* Address for reprints: Professeur J. F. Obadia, Hôpital Cardiothoracique Louis Pradel 28, avenue du Doyen Lépine—69677, Bron, France (Email: jf.o{at}chu-lyon.fr).

Aortic and mitral prosthetic valve endocarditis with extensive abscess is generally considered to be a critical situation with no satisfactory technical solution. ^1,2 Although we respect the principle of wide resection proposed by Tirone David, ³ we report a simplified reconstruction solution using an aorto-mitral monobloc.

Technique

The first step consists of wide resection including the aortic and mitral valve prostheses, the proximal aorta, and the aorto-mitral curtain. This resection leaves a single gaping aorto-mitral orifice and 2 button-shaped coronary ostia. The second step of reconstruction can be simplified, when it is planned, using either a monobloc aorto-mitral homograft (Figure 1), for which we have already described the implantation technique, ⁴ or a monobloc mechanical prosthesis prepared before starting cardiopulmonary bypass to limit the duration of the crossclamp time (Figure 2).

View larger version (134K): [in this window] [in a new window]   Figure 1. Monobloc aorto-mitral homograft. All hearts harvested for our tissue bank are dissected so the homograft includes the aortic valve and mitral valve in a single monobloc. When the surgeon thaws the monobloc, he or she can continue dissection to obtain an aortic valve, a mitral valve, or a bivalvular monobloc as necessary.

View larger version (141K): [in this window] [in a new window]   Figure 2. Monobloc aorto-mitral mechanical valve replacement. A St Jude Medical mitral valve prosthesis and a St Jude Medical tubular aortic valve prosthesis (St Jude Medical Inc, St Paul, Minn) were implanted on a sheet of Dacron. A fold in the Dacron was created by interrupted sutures to allow implantation of an additional patch to reconstruct the roof of the left atrium. The dimensions of the prostheses can be determined preoperatively on the basis of the dimensions of the patient's infected prostheses, and the orifice left by resection is always sufficiently large and flexible to receive an adapted monobloc prosthesis.

Patients

Five patients aged 36 to 56 years underwent reoperation for the third to fifth time with extensive abscessing infectious endocarditis on aortic and mitral prostheses. One patient also had tricuspid extension with a ventricular septal defect. All 5 patients had severely altered hemodynamics and sepsis, and 3 of them were considered to be inoperable in another center before being referred to us. The microorganism isolated was Staphylococcus aureus in 2 cases, Candida glabrata in 1 case, Kingella dentrificans in 1 case, and Streptococcus sanguis in 1 case. The ejection fraction was always preserved (>60%).

Results

Because of the availability of homografts in our tissue bank, 3 patients received an aorto-mitral homograft and the other 2 patients had to be treated by monobloc mechanical reconstruction. One patient also required placement of a tricuspid bioprosthesis and repair of an interventricular septal defect (mean crossclamp time: 186 minutes, mean cardiopulmonary bypass time: 231 minutes). All 5 patients recovered from the episode of endocarditis requiring surgery with satisfactory long-term echocardiographic follow-up of the reconstruction. However, 1 patient who was comatose on arrival in the operating room never recovered after surgery and died of neurologic complications 6 months after the operation. Another patient died of progression of pulmonary abscesses 4 months after the operation. One patient completely recovered from an episode of infectious endocarditis (apyrexia for >1 year without antibiotics) but died suddenly after a follow-up of 18 months. The diagnosis of new infectious endocarditis was confirmed by the presence of vegetations and rupture of the posterior papillary muscle insertion of the homograft. Two patients (1 with a homograft and 1 with monobloc mechanical valve replacement) are still alive with a follow-up of 5.5 years and 2 years, respectively. Totally afebrile mitral regurgitation developed in the patient with a homograft after 21 months, requiring reoperation for mitral valve replacement with a St Jude Medical prosthesis (St Jude Medical Inc, St Paul, Minn). No infection was detected on intraoperative samples, and the patient remains asymptomatic 5.5 years after the episode of infectious endocarditis. Follow-up echocardiography of the remaining aortic homograft and the St Jude Medical mechanical prosthesis was perfectly satisfactory. One patient with a monobloc aorto-mitral prosthesis and tricuspid bioprosthesis is in satisfactory condition apart from right ventricular failure, which is well controlled by medical therapy.

Discussion

The 2 postoperative deaths and the secondary death were related to the severe general state of these patients. However, cure of the valvular septic process in 5 patients confirms the relevance of an oncologic surgical technique comprising inevitably destructive wide resection, followed by reconstruction, which can be long and difficult. Tirone David and colleagues ⁵ proposed progressive reconstruction with successive insertion of a mitral valve prosthesis followed by an aorto-mitral pericardial patch, an aortic valve prosthesis, and finally another pericardial patch on the roof of the right atrium. We propose a monobloc reconstruction technique that is both simpler and more rapid provided this reconstruction is planned preoperatively. The monobloc aorto-mitral homograft can be dissected to obtain an aortic homograft comprising variable degrees of the mitral valve depending on the particular circumstances. When an aorto-mitral homograft is not available, construction of a monobloc mechanical valve before starting cardiopulmonary bypass enables a reduction of the clamping time. This technique is indicated in patients initially considered to be in critical condition, whose prognosis depends more on the general state than on the local lesions, which corroborates the analogy with cancer surgery. Of the 2 patients still alive today, 1 received a homograft and 1 received a mechanical valve, which suggests that the concept of extended resection may be more important than the nature of the substitute used for repair. These results should be confirmed in a larger population with a longer follow-up.

References

1. Haydock D, Barratt-Boyes B, Macedo T, Kirklin JW, Blackstone E. Aortic valve replacement for active infectious endocarditis in 108 patients. A comparison of freehand allograft valves with mechanical prostheses and bioprostheses. J Thorac Cardiovasc Surg 1992;103:130-139.[Abstract]
   
2. Pulpon LA, Crespo MG, Sobrino M, et al. Recalcitrant endocarditis successfully treated by heart transplantation. Am Heart J 1994;127(4 Pt 1):958-960.[Medline]
   
3. David TE. The surgical treatment of patients with prosthetic valve endocarditis. Semin Thorac Cardiovasc Surg 1995;7:47-53.[Medline]
   
4. Obadia JF, Raisky O, Sebbag L, Chocron S, Saroul C, Chassignolle JF. Monobloc aorto-mitral homograft as a treatment of complex cases of endocarditis. J Thorac Cardiovasc Surg 2001;121:584-586.[Free Full Text]
   
5. David TE, Feindel CM, Armstrong S, Sun Z. Reconstruction of the mitral anulus. J Thorac Cardiovasc Surg 1995;110:1323-1332.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Obadia, J.F. Articles by Raisky, O. Search for Related Content PubMed PubMed Citation Articles by Obadia, J.F. Articles by Raisky, O. Related Collections Valve disease