Surgical Repair of Mitral and Tricuspid Valves After Cardiac Transplantation
Masaharu Yoshikawa, PhD,
Shirou Tomari, MD1,
Akihiko Usui, PhD2,
Yuichi Ueda, PhD2
Division of Cardiovascular Surgery, Toyota Kosei Hospital Toyota, Aichi, Japan
1 Division of Cardiovascular Surgery, Komaki Municipal Hospital Komaki, Aichi, Japan
2 Department of Cardiothoracic Surgery, Nagoya University Graduate School of Medicine Nagoya, Aichi, Japan
Masaharu Yoshikawa, PhD, Tel: +81 565 43 5000, Fax: +81 565 43 5100, Email: m-yoshikawa{at}toyota.jaaikosei.or.jp, 500-1 Ibobara, Jousui-cho, Toyota, Aichi 470-0396, Japan.
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ABSTRACT
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A 43-year-old man underwent mitral valve repair for mitral valve insufficiency due to infective endocarditis, and tricuspid valve repair for iatrogenic chordal rupture due to multiple endomyocardial biopsies after orthotopic cardiac transplantation. Valve repair using no artificial material is feasible, instead of valve replacement, to decrease the risk of recurrent infective endocarditis and enable further biopsies.
Key Words: Biopsy • Endocarditis • Heart Transplantation • Mitral Valve Insufficiency • Tricuspid Valve Insufficiency
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INTRODUCTION
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Atrioventricular valve incompetence in the transplanted heart is not uncommon and is mostly treated by medication. However, progressive valve dysfunction reduces the patient’s quality of life and negates the benefit of heart transplantation. We report a case of successful double valvuloplasty without artificial materials for severe tricuspid valve regurgitation (TR) caused by iatrogenic chordal damage and mitral valve regurgitation (MR) that was suspected to have been caused by infectious endocarditis (IE) after cardiac transplantation.
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CASE REPORT
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A 43-year-old man with dilated cardiomyopathy underwent orthotopic heart transplantation in the USA. The donor was a 20-year-old woman with no history of heart disease who had suffered a fatal traffic accident. Transthoracic echocardiography (TTE) 17 days after the transplantation demonstrated no MR, trivial TR, and an ejection fraction of 50.5%. Four years later, TTE showed severe TR due to frequent biopsies, with no MR. At 5 years post-transplant, the patient was treated with oral antibiotics for recurrent low-grade fever. Two years later, he was admitted with mild symptoms of heart failure, high fever, and marked inflammatory findings. TTE findings of severe TR and severe MR made us suspect IE. No organisms were isolated from microbial culture of several blood samples. Serologic screening also revealed no evidence of infection with cytomegalovirus or fungal organisms. Two weeks after initiating antimicrobial therapy, the inflammatory response subsided. TTE still indicated severe MR, severe TR, and pulmonary hypertension of approximately 41 mm Hg in systole, which was estimated by the continuous Doppler method. A repeat sternotomy was performed. Inspection of the pericardial sack revealed that the transplantation had been carried out with standard bicaval anastomoses. Cardiopulmonary bypass was established with selective bicaval venous drainage. Cardiac arrest was induced with antegrade cold blood cardioplegia. Upon entering the left atrium, inspection of the mitral valve revealed prolapse of both valve leaflets adjacent to the posteromedial commissure, resulting from several ruptured marginal chordae tendineae, and incomplete coaptation between the middle scallop and the posteromedial scallop. There was no apparent vegetation or fragile leaflet surface suggesting active infection. The posterior leaflet was smooth and just partially thickened, which seemed to result from a healed state of inflammation. The edges of both mitral leaflets were sutured together to close the posteromedial commissure. The dilated cleft was corrected by partial annular plication with a Reed’s horizontal mattress suture, using autologous pericardial pledgets. The tricuspid valve was also exposed and inspected. The chordae tendineae of the posterior and septal leaflets were ruptured due to multiple biopsies. These leaflets were sutured together to construct a functionally bicuspid valve. A small prolapsing segment of the anterior leaflet was corrected by suture plication of the leaflet margin. Transesophageal echocardiography after weaning from cardiopulmonary bypass showed a good result, with trivial MR and mild TR. Postoperative recovery was smooth. On the 22nd postoperative day, the patient was discharged without recurrence of infection. Four years after the valve surgery, he remained asymptomatic with TTE findings of trivial MR, mild TR, and no recurrent infective signs. Endomyocardial biopsy of the right ventricle revealed no rejection.
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DISCUSSION
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It would appear that several factors can lead to atrioventricular valve incompetence in the transplanted heart.1–6 Iatrogenic chordal damage resulting from endomyocardial biopsies is still considered to be a common cause of TR.5 With MR, myxomatous degeneration, iatrogenic chordal damage and infective endocarditis have been reported as intraoperative findings.2–4 The clinical history of our patient suggested that TR resulted from iatrogenic chordal injury during multiple biopsies. As microbial culture did not yield any causative organisms, we were unable to confirm the diagnosis of IE. However, intraoperative findings in the mitral leaflets and the clinical course, which exhibited preoperative development of MR with increased inflammatory response, were strongly indicative of this diagnosis. Thus to avoid recurrence of IE, no artificial material, except monofilament suture, was used for mitral valve repair. We also made every effort to avoid tricuspid valve replacement as it was necessary to be able to perform biopsies to maintain the transplanted heart as well as to decrease the risk of prosthetic valve infection.
IE in a transplanted heart is an uncommon and life-threatening diagnosis for a patient in an immunosuppressive state.7,8 Intravenous antimicrobial therapy was effective in this patient and enabled him to undergo surgical intervention. His protocol of surveillance endomyocardial biopsies was changed after this surgery. Tissue Doppler imaging, a noninvasive examination, was adopted for assessment of ventricular function to reduce the frequency of surveillance biopsies. When tissue Doppler demonstrates a significant change in comparison with previous findings, a myocardial biopsy is planned. Currently, the procedure for myocardial biopsy is to remove a specimen from the inferior part of the right ventricular septum to reduce the risk of tricuspid valve chordal injury. Suture valvuloplasty for both atrioventricular valves after orthotopic heart transplantation can be performed safely with good short-term success. This surgical strategy is feasible to sustain the valuable transplanted heart and allow endomyocardial biopsy through the tricuspid valve.
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Figure 1. Preoperative transesophageal echocardiography showing severe mitral regurgitation and a left atrial suturing ridge (arrow) from the initial cardiac transplantation. LA = left atrium, LV = left ventricle.
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REFERENCES
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Asian Cardiovasc Thorac Ann 2009;
17:294-296
© 2009 by SAGE Publications
DOI: 10.1177/0218492309104766
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Mitral and tricuspid valve repair 21 years after cardiac transplantation
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140(1):
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