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A ten-year-old girl with history of rheumatic fever for eight years presented with worsening dyspnea upon exertion in the prior four to five months with NYHA class III heart failure. Surgeons found that the patient’s anterior mitral valve leaflet was thickened, she had a doming posterior mitral valve leaflet with restricted mobility, and she had moderate to severe mitral regurgitation. The patient’s mitral valve annulus was 40 mm.
Surgeons also found thickened aortic valve leaflets with a retracted and deficient left coronary cusp. The patient had severe aortic regurgitation, diastolic flow reversal in the abdominal aorta, and a dilated left ventricle with good left ventricle function. The aortic annulus was 25 mm. Based on this information, the team planned for mitral valve repair with aortic valve repair.
The Surgery
After a sternotomy, the pericardium was harvested and fixed in 0.6 percent glutaraldehyde, and cardiopulmonary bypass was established between the aorta and bicavae. The mitral valve was addressed by performing peeling of AML. The A2 to A3 segment was tethered, fenestration was performed, secondary chordate were released, and a 30 mm annuloplasty ring was placed by supraseptal approach.
When the aortic valve was assessed, the leaflets were observed to be thickened and retracted with rheumatic etiology. The decision was made to perform neocuspidization of aortic leaflets with glutaraldehyde treated pericardium.
To perform the neocuspidization, surgeons used a formula inspired by Dr. Praveen Tambrallimat with several modifications (1). They used an additional 5 mm for height and width of the leaflet instead of 1-2 mm for suturing of newly made aortic leaflets. As the height of coaptation is said to be the marker for long term success rates, the team used the additional 1-2 mm as the height and width of leaflets. They were not able to achieve the coaptation height of more than 10 mm. If they had used the additional 5 mm, they could have achieved the coaptation height of more than 10 mm.
With the help of a valve sizer, the aortic annulus was measured to be 25 mm. Using silk thread, the leaflets’ length at the level of annulus was also measured. The formula for making new leaflets—the size of the annulus plus 5 mm—was used as the marker for the height and width of the leaflets. For the bicuspid valves, the team divided the annulus into three equal parts and made neocommisures. Using these measurements, three cusps were created.
In this case, the annulus was 25 mm. The height and width of the leaflets was determined to be 30 mm, and this measurement was made over the treated pericardium and cut accordingly. The newly made pericardial valve leaflets were then fixed to the annulus by continuous polypropylene sutures. The sutures of adjacent leaflets were fixed to the annulus and hitched, and this was repeated at all three commissures. A Fratters stitch was taken to assess for prolapse of the leaflets. The aorta was then closed.
The postoperative echocardiogram showed mild mitral regurgitation with good coaptation of the newly formed aortic valve leaflets, which had a coaptation height of 11 mm. Upon biopsy, there was no inflammation of leaflets. At her follow up, the patient was asymptomatic and had no significant lesion on an echocardiogram.
From this case, surgeons concluded that the uses of the Ozaki repair can be expanded to include children suffering from rheumatic heart disease, with satisfactory short-term results.
References
- Tambrallimath PR, Chatterjee S, Bose S. Aortic Valve Repair With All Cusp Replacement Using Treated Autologous Pericardium: The Ozaki Technique. August 2019. doi:10.25373/ctsnet.9589007.
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