Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 129--132

Mitral regurgitation jet around neoannulus: Mitral valve replacement in erysipelothrix rhusiopathiae endocarditis


Rahul Basu1, Prabhat Tewari2,  
1 Department of Anaesthesia, Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, City Hospital, Nottingham, United Kingdom
2 Department of Anaesthesia, SGPGIMS, Raibarely Road, Lucknow, Uttar Pradesh, India

Correspondence Address:
Prabhat Tewari
Department of Anaesthesia, SGPGIMS, Raibarely Road, Lucknow, Uttar Pradesh - 226 014
India

Abstract

A 50-year-old male presented with erysipelothrix rhusiopathiae (ER) endocarditis of the mitral valve, severe mitral regurgitation, and heart failure. The ER endocarditis destroyed the native mitral annulus therefore a new annulus was created for the suspension of the mitral bioprosthesis. Postoperative neoannulus dehiscence and leak prompted to redo surgery where transesophageal echocardiography (TEE) played an important role in pointing out the exact location of perineoannular leaks for repair.



How to cite this article:
Basu R, Tewari P. Mitral regurgitation jet around neoannulus: Mitral valve replacement in erysipelothrix rhusiopathiae endocarditis.Ann Card Anaesth 2013;16:129-132


How to cite this URL:
Basu R, Tewari P. Mitral regurgitation jet around neoannulus: Mitral valve replacement in erysipelothrix rhusiopathiae endocarditis. Ann Card Anaesth [serial online] 2013 [cited 2021 Nov 29 ];16:129-132
Available from: https://www.annals.in/text.asp?2013/16/2/129/109765


Full Text

 Introduction



Infective endocarditis of the native valve is one of the most serious of all the clinical infections. It leads to formation of vegetation and annular abscess and ultimately destruction of the valve tissue depending on the virulence of the infection and also the host immunologic factors. Once this state is reached, surgical intervention with valve replacement is the only effective treatment but even this may pose postoperative problems

 Case Report



A 50-year-old male diagnosed with erysipelothrix rhusiopathiae (ER) endocarditis of the mitral valve (MV) presented for urgent MV surgery. The patient consented for urgent mitral valve replacement. Intraoperative transesophageal echocardiography (TEE) showed echo dense lesions on both the mitral valve leaflets (MVL) with two regurgitant jets on color flow Doppler (CFD). The first was central and the second was an eccentric jet, posteriorly directed, wall hugging jet that encircled the entire left atrium (LA). The mitral regurgitation (MR) was classed as severe because calculated MR jet area was more than 6 cm 2 and vena contracta was more than 6.5 mm. The left ventricle (LV) was hyperdynamic with mild right ventricular (RV) systolic dysfunction. There was significant tricuspid regurgitation (TR) and the peak right ventricular systolic pressure (PRVSP) was approximately 35 mmHg pointing to elevated pulmonary artery pressure. The patient had severely restricted neck movements with fixed flexion deformity, pain, and reduced mouth opening due to recent cellulitis due to ER infection.

In the anesthetic room (AR) the patient was attached to routine monitors and because of his neck condition fiberoptic bronchoscope guided awake endotracheal intubation was done under sedation using remifentanyl infusion (0.05-0.1 μg/kg/min). Patient remained hemodynamically stable and afterwards general anesthesia was administered with etomidate and midazolam. Remifentanyl infusion (0.25 μg/kg/min) and propofol infusion (50-100 μg/kg/min) were used for maintenance of anesthesia. Pancuronium was used for muscle relaxation.

After aortic and superior and inferior vena cave cannulation cardiopulmonary bypass (CPB) was instituted. Postcardioplegic arrest, the transseptal route was used to approach MV. There were multiple small abscesses on the native MV annulus of the posterior leaflet. As putting sutures on native annulus was nearly impossible a neoannulus was created by suturing a crescent of Teflon patch (BARD PTFE felt; IMPRA, Inc. Tempa, Arizona, USA) nearly 1 cm above the posterior annulus into the LA wall with the ends sloping down to meet the anterior annulus just beyond the commissures. A 25 mm perimount bioprosthetic valve (Edwards LifeSciences, USA) was suspended on to this neoannulus posterolaterally and native annulus antero-medially. Post CPB TEE evaluation revealed a well-seated bioprosthetic valve with good leaflet excursion. On TEE the neo-annulus was visualized as a ridge between the LA and LV [Figure 1]. The patient was weaned off CPB with minimal ionotropic support and he did well in the first week in the postoperative period.

But on the eighth postoperative day the patient experienced sudden breathlessness and showed signs of shock. On bedside emergency transthoracic echo (TTE) the cardiologist reported a large paravalvular leak and subsequently the patient was taken up for emergency reoperation to explant the MV bioprosthesis and replace it with a new one. The patient was intubated under remifentanyl sedation using fiberoptic bronchoscope as it was done during the first surgery and then general anesthesia was administered. Intraoperative TEE, however, clearly demonstrated that the leak was not paravalvular but it was a large para-neoannular leak between the neoannulus and the LA wall. The jet hugged the posterior aspect of the LA, and circumnavigated the atrium [Figure 2]. PA pressures were elevated (estimated at 55 mmHg from TR jet) and the RV was dilated but LV function appeared to be preserved. TEE findings were confirmed at surgery and the surgeon did not touch the mitral bioprosthesis at all. It was noted that few sutures placed on the Teflon patch and LA had dehisced. Interrupted and pledgeted sutures were placed to repair the leak and secure the patch on to the LA. The patient was weaned from CPB with moderate systemic pressures on moderate doses of inotropes. On the repeat post-CPB TEE study, on ME 4C view at ° scan angle, a new regurgitant jet was observed, which seemed to arise somewhere from the same place where repair was done, that is, posteriolateral aspect of neoannulus [Figure 3]. But on further detailed TEE examination, when the scan angle was rotated beyond 90° (ME long axis view), it became clear that this leak was distinct and arose from the posteriomedial aspect of the neoannulus [Figure 4]. This jet was not seen pre-CPB and appeared to be distinct from the first leak. It needed further repair under CPB. The heart was arrested again and the surgeon found loose sutures at the same location. The new pledgeted sutures were placed to fortify the initial suture line. The patient needed intraaortic balloon counterpulsation (IABP) and three inotropic support to facilitate separation from CPB. A final TEE check did not show any residual leak. The patient made a slow but essentially uneventful recovery after the second surgery and was discharged home 4 weeks later.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Discussion



Infective endocarditis is a well-established cause of valvular heart disease and carries a high morbidity and mortality. The annual incidence of ER infection is reported to be twenty two cases per million populations in UK and Wales of which one percent develop septicaemia. Ninety percent of these septic patients-develop endocarditis. Out of these, seventy percent have aortic valve involvement. Up till now only about sixty cases of endocarditis have been reported in world literature. Involvement of MV is very rare. [1] Surgery should be performed urgently as mortality is high once heart failure sets in. [2] Isolated MV endocarditis can present with a varied picture including vegetations, chordal rupture, leaflet abscess/perforation, and annulus abscess. Despite antimicrobial therapy, surgical intervention remains an indispensable adjunct to its management. Recently, MV repair has been shown to be useful. [3],[4] In the present patient MV replacement became mandatory due to the extreme virulence of ER and the effective destruction of the MV annulus. Intraoperative TEE was useful in demonstrating vegetations on the MV and quantifying severity of MR. Surgery was complicated by friability of the native annulus and neighbouring tissues. It was felt that placement of the bioprosthetic ring directly on to native annulus could increase the risk of A-V groove rupture. [5],[6] Creation of a neoannulus therefore became necessary. The drag on this new annulus, probably, caused tension on the primary stitches resulting in early para-neoannular leak. It was difficult on TTE to locate the exact site of the leak and was described as paravalvular prompting the surgeon to consider replacement of the prosthesis. Intraoperative TEE, however, provided excellent views enabling us to diagnose a paraneoannular leak coming from the posterio-lateral aspect of the mitral annulus between neoannulus and LA wall. The bioprosthesis was seen to be functioning well. In view of the TEE findings the surgical plan was modified to fortify the leak area with extra sutures rather than risk a second valve replacement. The second regurgitant jet, which was small in size, was not seen in the first instance. It is possible that it was obscured by the primary jet and was therefore missed or else it may have been created iatrogenically during the second surgery. During the creation of new annulus the normal mitral annular morphology was lost thus standard nomenclature to exactly pinpoint the jet location could not be used. The second jet seemed to be free floating [[Figure 3] ME 4C view] and initially seemed to arise posterior-laterally but on further interrogation it became clear that actually it originated from the posterior-medial aspect of the neoannulus [[Figure 4] modified ME LAX view]. The surgeon again confirmed that TEE had located the leak accurately. This shows the importance of thorough meticulous TEE examination after complex MV surgery under difficult conditions. Adequate time should be spent to ensure the absence of remnant pathologies that may be a crucial determinant of patient outcome. [7],[8]

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