Early failure of mitral valve repair with anterior leaflet pericardial patch augmentation in rheumatic and radiation-induced valvulitis.

Abstract

Rheumatic mitral valve disease remains an important cause of mitral regurgitation (MR), accounting for 7% to 15% of organic MR cases in large epidemiologic studies (1,2). Similarly, a history of radiation to the mediastinum, as is common in the treatment of several malignancies, is associated with future valve dysfunction in up to one-third of patients. Mitral valve repair (MVr) is favored over replacement for severe primary MR; this is due to a significant 30-day and mid to long-term mortality benefit, as well as a reduction in peri-operative complications (3,4). However, due to ongoing inflammation and leaflet infiltration, MVr in rheumatic or radiation-induced valvulitis may be associated with decreased durability and an increased risk of reoperation (5). In order to improve outcomes of MVr in these populations, adjunctive reparative procedures have been introduced. One such technique involves the use of autologous or bovine pericardium to reconstruct or enlarge the anterior mitral leaflet (AML) and normalize its coaptation with the posterior leaflet, with further reinforcement from a supporting annuloplasty ring (Figure 1) (6). While small studies suggest excellent mid-term survival with this approach, moderate or greater recurrent MR and reoperation occurs in 11.2% and 4.6% of patients, respectively, with rheumatic MR. Poor outcome data exists in the literature regarding MVr techniques for radiation-induced valvulitis (6,7). Herein, we provide an in-depth clinical and imaging appraisal of two such cases, with a focused review on pathophysiology and management. Open in a separate window Figure 1 MVr utilizing an annuloplasty ring and AML pericardial patch augmentation. (A) Schematic of AML pericardial patch augmentation MVr. There is a reconstructed and enlarged AML, normalized anterior and posterior leaflet coaptation, and reinforcement from a supporting annuloplasty ring; (B,C) systolic and diastolic transesophageal echocardiography mid-esophageal four-chamber views. Displayed is the augmented anterior mitral leaflet and pericardial patch (red arrow). MVr, mitral valve repair; AML, anterior mitral leaflet; PML, posterior mitral leaflet.