A 57-year-old man was admitted to the hospital due to hyperleukocytosis. Echocardiography revealed irregularly shaped vegetation (size, 25 × 15 mm) attached to the anterior leaflet of the mitral valve. The vegetation exhibited oscillation and was connected to the thickened aortic valve. Color flow imaging showed severe insufficiency of both the aortic and mitral valves with perforation in the AMC (Fig. 1). Chest X-ray revealed bilateral lung congestion due to acute heart failure. Therefore, emergency surgery was indicated.
The heart was approached via median full sternotomy. An oblique incision was made in the ascending aorta under conditions of cardiac arrest. The aortic valve was bicuspid (type 1). Vegetation was observed at the non-coronary cusp, extending to the AMC. The mitral valve was exposed via the superior trans-septal approach. The anterior leaflet was thickened and had attached vegetation. Debridement of the infected tissue led to a defect in the middle portion of the anterior mitral annulus, AMC, and non-coronary cusp.
For reconstructing the defective parts, a glutaraldehyde-treated bovine pericardial patch (Model 4700, Edwards Lifesciences, Irvine, CA, USA) was folded to make a three-portion patch (Fig. 1a). The triangular portion (AMC portion) of two pericardial patches was sutured to the AMC remnant using continuous sutures. Pledgeted everted mattress sutures were placed around the mitral annulus, and the anterior rim was reconstructed with the pericardial patch (MV portion). A 23-mm mechanical valve (Abbott Laboratories, Chicago, IL, USA) was tied down in the intra-annular position of the aortic annulus in a manner wherein the sutures pass through the aortic annulus and the rectangular portion (AV portion) of the pericardial patch. Finally, a 28-mm mechanical valve (Abbott Laboratories, Chicago, IL, USA) was tied down in the mitral annulus (Fig. 2b).
Cardiobacterium valvarum was isolated on blood culture. Vancomycin and ceftriaxone were intravenously administered for 4 weeks postoperatively. Postoperative echocardiography revealed normal cardiac function with no significant perivalvular leakage. The patient displayed complete recovery and was discharged on postoperative day 33. The patient was symptom-free at his 1-year follow-up and exhibited normal laboratory and echocardiographic findings.