Pediatric mitral valve reconstruction in acute endocarditis

Although acute endocarditis is still a rare disease in the pediatric population, heart valve repairs in children have become procedures of choice, especially in emergency settings. We present a case of an 11-year-old patient with acute endocarditis and subsequent valve incompetence after infective destruction, who underwent extensive mitral valve (MV) repair with an individually designed surgical technique.
The 11-year-old boy was admitted to the Department of Pediatric Cardiac Surgery because of heart failure presenting with hectic temperature up to 40°C and clinical signs of sepsis with concomitant MV incompetence. The boy was suffering from shortness of breath and dyspnea during exercise with NYHA class II/III. Bacteriological analysis showed Staphylococcus aureus cultures obtained from blood and a healing wound on the leg. Antibiotic treatment was started upon an antibiogram. Due to clinical signs of endocarditis, transthoracic echocardiography (TTE) was performed, showing an image of a huge vegetation (24 × 12 mm) attached to the anterior mitral leaflet. The diagnosis was confirmed by subsequent transesophageal echocardiography (TEE) examination that showed more precisely invagination of the vegetation into an MV orifice, which caused hemodynamically significant valve incompetence (Figs. 1 A, B).
The patient was referred for emergency operative treatment after 2 weeks of advanced antibiotic therapy, which resulted in fever normalization prior the surgery. Transesophageal echocardiography performed in an operating room before the operation showed significant MV incompetence without leaflet prolapse and primary chordal disruption (type I – following Carpentier classification), which suggest leaflet(s) perforation. In addition, TEE revealed that the vegetation originated from the region of the P3 annulus, posterior leaflet and posteromedial commissure, while an empty annular abscess cavity was filled with mixed blood stream from both the atrial and ventricular side.
After hypothermic cardiopulmonary bypass institution with typical bicaval cannulation, the right atrium was opened and through an interatrial septum incision good exposure of the left atrium with the MV vegetation was achieved. The vegetation was carefully dissected with a margin of uninfected tissue showing a large P2/P3 perforation and an empty abscess cavity of the P3 annulus. Primary chordae were not disrupted. After local administration of Betadine a pericardial patch...


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