ABSTRACT
An 82-year-old man was referred to our hospital because of fever and disequilibrium. Brain magnetic resonance imaging showed acute multiple cerebral infarctions with multiple small intracerebral hemorrhages. The laboratory tests revealed an elevated inflammatory response, and two separate sets of blood cultures were positive for Streptococcus oralis. Transesophageal echocardiography revealed a single site of vegetation (13×11 mm) of the mitral anterior annulus. The vegetation apparently did not involve the intervalvular fibrous body. Moderate mitral regurgitation and mild to moderate aortic regurgitation were detected. Early surgical intervention was considered, but there was a high risk of operative mortality. We thus initially performed only medical treatment. Transesophageal echocardiography was again performed 12 days after his admission and revealed vegetation of the mitral anterior annulus progressing to the aortic annulus via the intervalvular fibrous body. It seemed to be difficult to control this progressive infective endocarditis with medical treatment. We therefore performed a semi-urgent operation. With an incision into the right-side left atrium, we identified the vegetation of the center of the mitral anterior leaflet progressing to the mitral anterior annulus. Subsequently, we added an aortotomy with Manouguian’s incision. We were able to remove all vegetation that was present in the aortic annulus, intervalvular fibrous body, and mitral annulus with a Commando operation. Finally, we performed double valve replacement with reconstruction of the intervalvular fibrous body and other lost cardiac structures using one boat-shaped bovine pericardial patch. He was discharged to home 34 days after surgery with no neurological complications and no recurrence of infective endocarditis. He also had no recurrence of infective endocarditis and no paravalvular leakage on either prosthetic valve at one year after the surgery.
ABSTRACT
Extensive calcification of the mitral annulus presents a formidable technical challenge to surgeons and increases the risk of serious complications such as intractable hemorrhage, atrioventricular disruption, and ventricular rupture during mitral valve surgery. We present a case of aortic and mitral valve replacements for a patient with extensive calcification of an intervalvular fibrous body. A 76-year-old woman was admitted with dyspnea on effort, leg edema and syncope. Transthoracic echocardiography showed severe aortic stenosis, and mitral stenosis with regurgitation, and extensive mitral annular calcification. Decalcification was performed with CUSA and we selected a trans-aortic-valve approach for decalcification of the intervalvular fibrous body. The calcification was left to a certain extent in order to preserve annular strength. Postoperative echocardiography showed no perivalvular leakage from either prostheses. The patient was transferred to a local hospital for further rehabilitation.