Mitral Valve Repair in Infective Endocarditis
Surgical treatment in mitral valve infective endocarditis (MVE) is indicated in patients with severe mitral regurgitation. Mitral valve replacement has traditionally been considered the standard treatment for MVE cases that are unresponsive to antibiotic therapy. This is due to concerns regarding the durability of mitral valve repair, recurrence of IE, and mitral regurgitation.
Since the first reported case of successful mitral valve repair for infective endocarditis by Dreyfus in 1990, several authors have suggested that in patients undergoing surgery for IE, mitral valve repair may be safely performed and is often associated with a better outcome. A systematic review by Ferringa et al. in 2007 underlined that mitral valve repair was possible in patients presenting with mitral valve endocarditis, with repair being associated with lower in-hospital and long-term mortality[JJ1] . Since this review, those findings have been supported by various published results: Rostagno et al. from Italy in 2017; Lee et al. from Taiwan in 2018; and El-Gabry et al. from Germany in 2019. In our case report, we present two cases of native valve infective endocarditis where mitral valve repair was performed.
Our first case involved a sixty-four-year-old gentleman who presented with mitral and aortic valve infective endocarditis, including severe aortic and mitral regurgitation. The mitral valve was accessed via Sondergaard’s groove; the flail A2 leaflet was visualized with old vegetations containing small debris on posterior leaflet. The posterior leaflet debris and the A2 leading edge was excised. Next, the mitral valve was repaired using two pairs of neochordae to A2 and a 30 mm annuloplasty ring. The water test displayed good results, and the lipstick test showed 10 mm coaptation. Subsequently, the patient also underwent a concomitant aortic valve replacement. A follow-up transthoracic echocardiogram at twelve months showed mild mitral regurgitation.
Our second case involved a fifty-three-year-old female who exhibited native mitral valve infective endocarditis with severe mitral regurgitation. The mitral valve was accessed via Sondergaard’s groove; perforation was visualized in the P2 leaflet with intact native cords. The P2 was excised, which left the leading edge unharmed. The posterior annulus at P2 was repaired with a pledgeted 2-0 Ti-Cron suture. The P2 was then reconstructed with a pericardial patch, followed by a 30 mm annuloplasty ring. The water test displayed satisfactory repair, and the lipstick test showed 10 mm coaptation. A follow-up TTE at one month showed mild mitral regurgitation.
Infective endocarditis is a challenging clinical condition. In the last twenty years or so, valve repair has been shown as a valuable alternative to valve replacement in mitral valve endocarditis. Valve repair is associated with decreased hospital mortality, long-term mortality, recurrent endocarditis, and an overall need for reoperation, when compared to valve replacement. Furthermore, repair decreases the risks related to prolonged anticoagulation. As a result, repair is preferred when technically feasible. However, the results of repair are dependent on the experience of the surgical team. Valve damage is also usually less extended in patients undergoing repair. Therefore, greater caution must be paid to assess its absolute superiority compared to valve replacement procedures.
1. Feringa et al. Mitral Valve Surgery for Endocarditis. Ann Thorac Surg 2007;83:564 –71. doi:10.1016/j.athoracsur.2006.09.023
2. Rostagno C. Mitral valve repair in infective endocarditis: which evidence?. Vessel Plus 2020;4:7. doi.org/10.20517/2574-1209.2019.29
3. Lee et al. Nationwide cohort study of mitral valve repair versus replacement for infective endocarditis. J Thorac Cardiovasc Surg 2018;156:1473-83. doi.org/10.1016/j.jtcvs.2018.05.010
4. M. El Gabry et al. Outcomes of mitral valve repair in acute native mitral valve infective endocarditis. Interactive CardioVascular and Thoracic Surgery 29 (2019) 823–829. doi:10.1093/icvts/ivz187
5. Rostagno et al. Role of mitral valve repair in active infective endocarditis: long term results. Journal of Cardiothoracic Surgery (2017) 12:29. DOI 10.1186/s13019-017-0604-6