Robotic Repair Of The Posterior Commissure In The Setting Of Bacterial Endocarditis
Neel K. Ranganath, MD, Didier F. Loulmet, MD, Travis C. Geraci, MD, Hamza S. Sadhra, MD, Mark V. Galstyan, Nieca Goldberg, MD, Peter J. Neuberger, MD, Eugene A. Grossi, MD.
NYU Langone Health, New York, NY, USA.
OBJECTIVE: We demonstrate totally endoscopic partial excision of the posterior commissure, including A3 and P3, and repair of a myxoid mitral valve with evidence of endocarditis.
METHODS: A 60yo woman with a history of mitral valve prolapse presented with exertional dyspnea. She received dental prophylaxis with amoxicillin two weeks prior to mitral repair. Intraoperative TEE confirmed severe mitral regurgitation due to posterior commissure prolapse. Five ports were placed in the right chest for the DaVinciXi and cardiopulmonary bypass was instituted via the femoral vessels. The heart was fibrillated, an endo-balloon clamp inflated with fluorescent guidance, and Del Nido cardioplegia was administered. Sondergaard's groove was opened and the PFO was closed with polytetrafluoroethylene (PTFE) suture. The left appendage was closed with two layers of PTFE suture. The mitral valve was globally myxoid, consistent with Barlow's disease, with posterior commissure prolapse due to multiple ruptured chordae. Fibrinous tissue attached to the margins of A3 and P3 was resected and sent for pathology and microbiology. Debridement of abnormal tissue included approximately half of A3 and P3. Abnormal secondary chordae of the anterior and posterior leaflets were divided. The posterior commissure was reconstructed with annular plication using a 2-0 braided suture, and re-approximation of the remaining leaflet halves of A3 and P3 with two layers of PTFE suture. A 36-mm posterior annuloplasty band was attached with interrupted 2-0 braided sutures, and re-testing of the valve revealed excellent coaptation without residual regurgitation. While the patient was rewarmed, the endo clamp was deflated (cross-clamp time 89 minutes), and the heart spontaneously returned to sinus rhythm. The atriotomy was closed with PTFE suture, and bypass was weaned without inotropic support.
RESULTS: Post-operative TEE demonstrated preserved LVEF without residual regurgitation, and the patient was extubated in the operating room. Microbiology did not reveal active infection but pathology reported "degraded bacterial colonies" on the excised valve tissue. No further antimicrobial therapy was given and the patient was discharged on postoperative day 3.
CONCLUSIONS: With endocarditis being responsible for the trigonal pathology, this case reinforces that isolated prolapse of the right trigonal region is rare due to degenerative disease.
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