The indications for valve surgery prior to completion of the full course of antibiotic therapy for endocarditis are related to two factors: hemodynamic instability and infectious complications, such as persistent sepsis; recurrent embolism; intracardiac abscesses, sometimes manifested by atrioventricular (A-V) block; or fungal endocarditis.
Advantages of repair
The advantages of the mitral valve repair in contrast to valve replacement include: lower post operative mortality, decreased risk of infection, decreased risk of embolism and the need for anticoagulation and preservation of the mitral valve apparatus that helps to maintain left ventricular function.
Our patient - repair
Mitral valve repair was possible in our patient, because the leaflet damage was not severe. Isolated posterior leaflet involvement made the surgery less complicated.
Another patient's surgery
The following surgery is presented through the courtesy of Dr. Delos M. Cosgrove and was carried out at The Cleveland Clinic Foundation. It is shown to demonstrate mitral valve repair for ruptured chordae tendineae in a patient with mitral valve prolapse. No endocarditis was present.
The left atrium is opened with a transseptal approach. This allows us to get a very good view of the mitral valve. Note the excellent view of the ruptured chordae tendineae. There are at least four ruptured chordae, all in the middle scallop of the posterior mitral leaflet.
The anterior leaflet appears normal with normal chordae.
The first normal chordae on each side is circled and held up with traction sutures. A knife is used to resect the damaged portion of the posterior leaflet and the entire middle scallop is excised. Sutures are then placed through the leaflet and, by varying tension on the traction sutures, an estimation of the closure line is determined. The two portions of the leaflet are then sewn together.
The surface of the anterior leaflet is measured with a sizer to determine the correct annular ring size to be used. Sutures are placed in the valve and the ring, which is then slid down into position.
The device is now well seated. The stent is removed and antegrade cardioplegia turned on. There is no evidence of prolapse or mitral regurgitation.
Post operative course
Our patient's post operative course following mitral valve repair was uneventful. She was continued on intravenous penicillin for a total of four weeks, and the majority of this therapy administered at home.
Discharge
At the time of discharge, because our patient is at high risk from previous endocarditis, she was advised to practice bacterial endocarditis prophylaxis by taking two grams of amoxicillin by mouth one hour before certain procedures involving dental work, the respiratory tract, the gastrointestinal tract and the genitourinary tract.