Valve repair in mitral regurgitation complicated by severe annulus calcification

Mitral valve surgery with extensive annular calcification: review of surgical techniques and postoperative complications

Mitral annular calcification (MAC) represents an important risk factor in mitral valve (MV) surgery. Despite several procedures having been described, no surgical treatment of choice has been established so far: whether a decalcification should be systematically carried out, or if the MV should be preferentially repaired rather than replaced. A review of the literature on patients undergoing MV surgery associated with MAC was performed. Studies were excluded if dealing with endovascular procedures or emergency surgery for associated endocarditis. Case reports were also not considered in the final analysis. The literature search identified 1429 potentially eligible studies, and 25 papers were eventually included. Several surgical techniques were described to approach this challenging condition. During MV surgery, the presence of MAC favors the occurrence of suboptimal intraoperative outcomes. MAC-related complications such as atrioventricular groove rupture, cerebrovascular accident, new permanent pacemaker implantation, intraoperative conversion from valve repair to replacement and mortality were analyzed. MV surgery in the presence of MAC considerably impacts the postoperative outcomes in terms of morbidity and mortality. A great variability of surgical techniques is reported, suggesting the need for standardization of the approach.

Prosthetic valve endocarditis caused by silent infection of methicillin-resistant coagulase-negative staphylococci

Surgery for prosthetic valve endocarditis in the mitral valve position is still challenging for surgeons. Reconstruction of the mitral annulus is useful for patients with a mitral annulus disputed by infection. Here, we report a redo mitral valve replacement using a collar-reinforced tissue valve, which was inserted into a mitral annulus reconstructed with a bovine patch. Though the preoperative blood culture detected Streptococcus anginosus, the intraoperative culture detected methicillin-resistant coagulase-negative staphylococci (MRCNS). MRCNS is rarely detected because of its indolent nature.

Mitral annular calcification in the elderly - Quantitative assessment

PURPOSE

To determine the reliability of subjective and objective quantification of mitral annular calcification (MAC) in elderly patients with severe aortic stenosis, to define quantitative sex- and age-related reference values of MAC, and to correlate quantitative MAC with mitral valve disease.

METHODS

In this retrospective, IRB-approved study, we included 559 patients (268 females, median age 81 years, inter-quartile range 77-85 years) with severe aortic stenosis undergoing CT. Four independent readers performed subjective MAC categorization as follows: no, mild, moderate, and severe MAC. Two independent readers performed quantitative evaluation of MAC using the Agatston score method (Agatston_MAC). Mitral valve disease was determined by echocardiography.

RESULTS

Subjective MAC categorization showed high inter-reader agreement for no (k ​= ​0.88) and severe MAC (k ​= ​0.75), whereas agreement for moderate (k ​= ​0.59) and mild (k ​= ​0.45) MAC was moderate. Intra-reader agreement for subjective MAC categorization was substantial (k ​= ​0.69 and 0.62). Inter- and intra-reader agreement for Agatston_MAC were excellent (ICC ​= ​0.998 and 0.999, respectively), with minor inconsistencies in MAC involving the left ventricular outflow tract/aortic valve. There were significantly more women than men with MAC (n ​= ​227, 85% versus n ​= ​209, 72%; p ​< ​0.001), with a significantly higher Agatston_MAC (median 597, range 81-2055 versus median 244; range 0-1565; p ​< ​0.001), particularly in patients ≥85 years of age. Agatston_MAC showed an area-under-the-curve of 0.84 to diagnose mitral stenosis, whereas there was no association of Agatston_MAC with mitral regurgitation (p ​> ​0.05).

CONCLUSIONS

Our study in elderly patients with severe aortic stenosis shows that quantitative MAC scoring is more reliable than subjective MAC assessment. Women show higher Agatston_MAC scores than men, particularly in the elderly population. Agatston_MAC shows high accuracy to diagnose mitral stenosis.

Mitral annular calcification: challenges and future perspectives

Mitral annular calcification (MAC) is a chronic degenerative process that implies calcification on the mitral support structure. It usually appears as a bystander to other cardiac pathologies hindering surgical treatment and increasing morbidity and mortality. When addressing the mitral valve, many surgical strategies have been suggested in the past with no clear consensus on what to choose. Moreover, and as transcatheter therapies have gained popularity over the last few decades, transcatheter mitral valve implantation has appeared as another alternative to conventional surgery. In this review, we aim at describing an overview of MAC, highlighting current challenges and treatment options as well as new potential alternatives.

Anatomy of mitral annulus insights from non-invasive imaging techniques

The mitral annulus (MA) is not a continuous ring of connective tissue from which are suspended mitral leaflets. Instead, it is a much more complex structure made up of a mix of fibrous, muscular, and adipose tissues. MA is a key structure in any type of mitral valve repair and recently it has been targeted for transcutaneous devices. Thus, a deep understanding of MA anatomy has never been more important. Traditionally, cardiac anatomy has been described using anatomic specimens. Currently, sophisticated non-invasive techniques allow imaging of MA with a richness of anatomical details unimaginable only two decades ago. The aim of this review is to provide a better understanding of the peculiar aspects of MA as they are revealed through these imaging techniques and discuss clinical implications related to this complex structure.

Hazards of Mitral Valve Replacement for Mitral Stenosis Caused by Massive Mitral Annular Calcium With or Without Aortic Valve Replacement for Aortic Stenosis

Mitral annular calcium (MAC) is common in older adults in the Western World and if extensive may cause mitral stenosis . The purpose of this report is to describe outcomes of 12 patients having mitral valve replacement for mitral stenosis secondary to massive MAC. Operatively excised deposits of calcium removed from the mitral annular area and the accompanying stenotic mitral valves were examined and then the patients' medical records were examined to confirm the diagnosis and the degree of valvular dysfunction. A total of 12 patients with massive MAC causing mitral stenosis and receiving mitral valve replacement with or without aortic valve replacement for aortic stenosis were observed in 2013 to 2015. Of the 12 patients, 7 died from 5 to 44 days (mean 19) after the valve operation and all had "stormy" postoperative courses; one survived 150 days and another, 600 days; the remaining 3 were improved by the operation and are alive 22, 27, and 59 months postoperatively. In conclusion, the high mortality in these patients suggests that mitral valve replacement in the setting of massive MAC be considered with caution.

Three-dimensional transesophageal echocardiography in degenerative mitral regurgitation

The morphology of mitral valve (MV) prolapse and flail may be extremely variable, with dominant and secondary dynamic lesions. Any pathologic valve appears unique and different from any other. Three-dimensional (3D) transesophageal echocardiography is a powerful tool to evaluate the geometry, dynamics, and function of the MV apparatus and may be of enormous value in helping surgeons perform valve repair procedures. Indeed, in contrast to the surgical view, 3D transesophageal echocardiography can visualize MV prolapse and flail in motion and from different perspectives. The purpose of this special article is not to provide a comprehensive review of degenerative MV disease but rather to illustrate different types of mitral prolapse and flail as they appear from multiple 3D transesophageal echocardiographic perspectives using a series of clinical scenarios. Because in everyday practice, 3D transesophageal echocardiographic images of MV prolapse and flail are usually observed in motion, each scenario is accompanied by several videos. Finally, the authors provide for each scenario a brief description of the surgical techniques that are usually performed at their institution.

Surgical management of mitral valve infective endocarditis with annular abscess and calcification in the setting of a leaking mycotic infrarenal abdominal aortic aneurysm: a case report

We present the case of a previously well seventy-four year old male caucasian grazier who presented with mild back pain and was subsequently found to have a large posterior mitral valve leaflet perivalvular abscess associated with mitral annulus calcification and a mycotic infrarenal abdominal aortic aneurysm (AAA) of Staphylococcal origin. He underwent a right axillofemoral bypass with oversewn aorta and a right to left femoral crossover graft, and a subsequent mitral valve repair with decalcification/debridement of the annulus and extensive posterior leaflet reconstruction with pericardium patch. Despite multiple sequelae and an extended intensive care and hospital stay, the patient was discharged home after six months.

Impact of mitral annular calcification on early and late outcomes following mitral valve repair of myxomatous degeneration

OBJECTIVES

Mitral annular calcification is associated with significant morbidity and mortality at the time of mitral valve surgery. However, few data are available describing the impact of mitral annular calcification on early and late outcomes following mitral valve repair in the current era.

METHODS

Between 2001 and 2011, 625 patients were referred for mitral valve repair of severe mitral regurgitation due to myxomatous degeneration. The mean patient age was 63.9 ± 12.7 years and 164 (26%) were female. Concomitant coronary artery bypass grafting was performed in 91 (15%) and 24 (4%) had previous cardiac surgery. Calcification of the mitral annulus was observed in 119 patients (19%), of whom complete debridement and extensive annulus reconstruction were performed in 14. The mean follow-up was for 2.4 ± 2.3 years.

RESULTS

There were no deaths within 30 days of surgery. Risk factors associated with mitral annular calcification included older age (odds ratio 1.05 ± 0.02 per increasing year), female gender (odds ratio 1.88 ± 0.42) and larger preoperative left atrial size (odds ratio 1.04 ± 0.03 per increasing mm) (all P<0.01). Severe renal impairment defined as a creatinine clearance <30 mL/min was observed in 9 patients, all of whom had mitral annular calcification. Intraoperative conversion to mitral valve replacement was performed in 19 patients (97% repair rate), 5 of whom had mitral annular calcification. Extension of mitral annular calcification into one or more leaflet scallops was observed for all patients who required conversion to valve replacement. Five-year survival, freedom from recurrent mitral regurgitation ≥ 2+ and freedom from recurrent mitral regurgitation ≥ 3+ was 88.1 ± 2.4, 89.6 ± 2.3 and 97.8 ± 0.8%, respectively. Mitral annular calcification was not associated with survival or recurrent mitral regurgitation.

CONCLUSIONS

Risk factors for mitral annular calcification in patients with myxomatous degeneration and severe mitral regurgitation include older age, female gender, severe renal dysfunction and larger preoperative left atrial size. Nevertheless, favourable early and late results can be achieved with mitral valve repair in this population.

Chordal replacement for leaflet prolapse in a posterior mitral valve with a calcified mitral annulus

Mitral annular calcification (MAC) is sometimes associated with Carpentier type 2 mitral valve regurgitation and is a challenge to repair. Complete annular decalcification and mitral valve reconstruction is considered the ideal treatment. This report demonstrates the success of chordal replacement and band annuloplasty without resection of the leaflet and MAC. We have followed the patient for 7 years postoperatively, with no progression of MAC and no regurgitation by echocardiography.

[Mitral valve surgery in patients with extensively calcified mitral annulus: long-term echocardiographic and clinical follow-up]

OBJECTIVE

The aim of this study was the analysis of long-term results in patients with hemodynamically significant mitral valve disease due to extensively calcified mitral annulus who underwent decalcification and patch reconstruction.

PATIENTS AND METHODS

Between 1996 and 2008 a total of 109 patients underwent surgery for extensive calcification and severe mitral insufficiency and mitral stenosis. The mean age of the patients (65 women and 44 men) was 66.4 ± 13.8 years. In 53 patients (49%) mitral valve repair was performed and the remaining 56 patients (51%) received a mitral valve replacement. Of the patients 64 (59%) required concomitant surgery. The mean follow up time was 96 ± 48 months.

RESULTS

The in-hospital and late mortality was 8.3% (9 patients) and 25.6% (28 patients), respectively. The actuarial survival rates at 5, 8 and 12 years were 88.1%, 76.2% and 66.1%, respectively. Echocardiographic follow-up presented a mitral insufficiency grade III in 4 patients (6%). None of the patients had a mitral insufficiency grade IV. A significant reduction of left atrium diameter, of the LVEDD as well as the mean transvalvular gradient was observed. Freedom from reoperation at 5 and 8 years was 96.4% and 91.8%, respectively. Systemic hypertension, diabetes mellitus, age older than 65 years, concomitant aortic valve replacement, concomitant procedures, chronic renal insufficiency and cardiac decompensation in the medical history were found to be predictors for significantly increased early or late mortality.

CONCLUSION

The long-term results strongly suggest that en bloc decalcification and patch reconstruction of the mitral annulus can be safely undertaken in high risk patients.

Folding mitral valvuloplasty without posterior leaflet resection for calcified mitral annulus

Mitral valve annular calcification has long been a challenge in repairing posterior mitral valve prolapse. Folding valvuloplasty of the posterior leaflet without resection provides a means of circumventing common procedural complications. This report demonstrates the success of folding valvuloplasty without resection in the treatment of mitral valve prolapse and severe annular calcification.

[Long-term echocardiographic and clinical follow-up after mitral valve surgery in patients with extensive calcified mitral annulus]

OBJECTIVE

The aim of this study is the analysis of long-term results in patients with hemodynamically significant mitral valve disease due to extensive calcified mitral annulus who underwent decalcification and patch reconstruction.

PATIENTS AND METHODS

Between 1996 and 2008 a total of 109 patients underwent surgery in the presence of extensive calcification, severe mitral insufficiency and mitral stenosis. The mean age of patients (65 women, 44 men) was 66.4±13.8 years. Mitral valve repair was performed in 53 patients (49%), while the remaining 56 patients (51%) received a mitral valve replacement. In all, 64 patients (59%) required concomitant surgery. The mean follow-up time was 96±48 months.

RESULTS

Inpatient and late mortality rates were 8.3% (nine patients) and 25.6% (28 patients), respectively. The actuarial survival rates at 5, 8 and 12 years were 88.1%, 76.2% and 66.1%. Echocardiographic follow-up demonstrated mitral insufficiency III in four patients (6%). No patients had mitral insufficiency IV. We observed a significant reduction in left atrium diameter, LVEDD as well as mean transvalvular gradient. Freedom from reoperation at 5 and 8 years was 96.4% and 91.8%, respectively. We found systemic hypertension, diabetes mellitus, age above 65 years, concomitant aortic valve replacement, concomitant procedures, chronic renal insufficiency and cardiac decompensation in the medical history as predictors for significantly increased early or late mortality.

CONCLUSION

The long-term results strongly suggest that en bloc decalcification and patch reconstruction of the mitral annulus can be safely undertaken in high-risk patients.

Mitral Valve Repair: Past, Present, and Future

Mitral valve repair is the operation of choice for mitral valve regurgitation, with appropriate selection. Studies have shown that mitral repair is associated with a decrease in both long-term thromboembolic complications and mortality. Since its initial description, various selection criteria and techniques of mitral valve repair have been discussed in the literature. This review serves as a synopsis of the previous achievements, present status, and possible future directions of mitral valve repair, specifically from an Asian perspective. Vast experience has been amassed in understanding mitral valve pathophysiology, and excellent surgical treatments for mitral regurgitation have been developed. With the efforts of pioneers in the field of mitral valve repair, standard surgical treatment strategies have been proven to restore the life-expectancy of patients with degenerative mitral regurgitation to that of the age-adjusted population. Minimally invasive techniques of mitral valve repair further reduce access trauma, and could potentially benefit patients previously excluded from conventional surgery.

Intra-atrial placement of a mitral prosthesis in a patient with severe mitral annulus calcification: a case report

An 88-year-old woman presented with increasing dyspnea and angina. She was found to have severe aortic stenosis, 2-vessel coronary artery disease, and severe mitral regurgitation. During surgery the patient was noted to have such severe mitral annular calcification that performing a conventional mitral valve replacement would have significantly increased the operative risk. Instead, an 8-mm Dacron graft was sutured onto the sewing cuff of a reversed 23-mm Mosaic porcine aortic valve (Medtronic, Minneapolis, MN, USA). The Dacron graft was then sutured to the left atrial wall surrounding the calcified mitral annulus. A bioprosthetic aortic valve replacement, along with a 2-vessel coronary artery bypass procedure, was also performed.

Mitral regurgitation: overview of current surgical techniques and future developments

Mitral regurgitation is a complex disease with many different etiologies, underlying dysfunctions and histologic alterations. Surgical correction of this condition dramatically improves the life expectancy and life quality of affected patients. The structure of the mitral valve lends itself to many surgical techniques. The purpose of this review is to offer readers an overview on this subject.

Management of left atrial endocardium after extensive thrombectomy

Thrombosis at the left atrium is a common phenomenon in patients with chronic mitral valve disease and atrial fibrillation. When thrombus organizes and evolves into chronic phase, clean thrombectomy can become a challenge during heart surgery because of dense adhesions and the lack of clean cleavage plane. Leaving residual thrombotic material or roughened endocardial surface after thrombectomy could be a potential source for further thrombosis and a nidus for thromboembolism. We recently managed such a patient successfully using extensive thrombectomy and endocardial coverage with a fresh autologous pericardial patch.

The use of autologous pericardium for complicated mitral valve annulus

The study aims to discuss annular repair using the autologous pericardial patch in cases with severe mitral ring calcification and endocarditis during mitral valve replacement. In the study, annular reconstruction was applied, during mitral valve replacement, to 8 patients who had extensive annular calcification or annular destruction due to endocarditis. After annular resection, a two-centimeter wide autologous pericardial patch was sutured continuously to the left ventricular wall close to the posterior annulus. After the valve sutures with pledgets were placed at the back of the pericardial patch, the other edge of the patch was sutured continuously to the left atrial posterior wall. Suturing was complete after the whole annulus was encircled. Thereafter, an appropriately sized mechanical prosthesis valve was used. One patient died postoperatively due to low cardiac output (early mortality 12.5%). Echocardiographical paravalvular leakage was not detected in any of the cases during follow-up. Annular dehiscence and other annular pathologies were also not detected. This reconstructive approach may positively influence mortality and morbidity in cases with complicated mitral pathologies.

Midterm results of edge-to-edge mitral valve repair without annuloplasty

OBJECTIVE

Edge-to-edge mitral valve repair is usually performed in association with annuloplasty, with rare exceptions. We retrospectively analyzed the results of ringless edge-to-edge repair, particularly in view of minimally invasive and percutaneous approaches.

METHODS

From November 1993 to December 2001, 81 patients underwent edge-to-edge mitral repair without associated annuloplasty. The cause was degenerative in most patients. In 32 patients the annulus was severely calcified. Type I lesions were present in 6 patients, type II lesions in 60 patients, and type III lesions in 15 patients. A double-orifice repair was done in 69 patients, and paracommissural repair was done in 12 patients. In 5 patients edge-to-edge repair was used as a rescue procedure.

RESULTS

There were 3 hospital and 4 late deaths, for a 4-year survival of 85% +/- 6.7%. At latest follow-up, 63 patients were in New York Heart Association classes I or II, and 9 patients were in classes III or IV. Nine patients required reoperation (89% +/- 3.9% overall freedom from reoperation at 4 years). Annular calcification was associated with a greater reoperation rate (77% +/- 22% vs 95% +/- 4.6% freedom from reoperation, P =.03). Intraoperative water testing and postrepair transesophageal echocardiography predicted late failure. Only 1 of 42 patients required reoperation in the follow-up period when annular calcification, rheumatic disease, or rescue procedure were not present as risk factors.

CONCLUSIONS

Our data confirm overall suboptimal results of the edge-to-edge technique when annuloplasty is not added to the repair. Annular calcification, rheumatic cause, and edge-to-edge repair done as a rescue procedure were associated with the worst outcome. Midterm results in selected patients encourage future developments in catheter-based edge-to-edge procedures.

Mitral valve surgery in patients with extensive calcification of the mitral annulus

OBJECTIVES

The objective of this work was to examine the clinical outcomes of mitral valve surgery in patients with extensive mitral annular calcification.

METHODS

Mitral valve surgery was performed in 54 patients (28 men and 26 women, mean age 63 +/- 14 years) with mitral regurgitation and extensive mitral annular calcification. Most patients (78%) were in New York Heart Association classes III and IV, 14 had coronary artery disease, and 9 had prior mitral valve replacement in which the calcium bar was not removed. The calcium bar was excised and a new mitral annulus was created by suturing a strip of pericardium onto the endocardium of the left ventricle from lateral to medial fibrous trigones and to the endocardium of the left atrium. The mitral valve was repaired in 12 patients and replaced in 42. In 23 patients the intervalvular fibrous body was reconstructed and the aortic valve was also replaced. Mean follow-up was 4.1 +/- 3.7 years and was complete.

RESULTS

There were 5 operative deaths and 11 late deaths. Five-year survival was 73 +/- 7%. Four patients needed reoperation and each survived. Freedom from reoperation at 5 years was 89 +/- 6%. Three patients had a stroke and 4 had anticoagulation-related hemorrhage, one of which was fatal. Five-year freedom from valve-related mortality or morbidity was 75 +/- 8%. Most survivors were in New York Heart Association functional classes II and III.

CONCLUSIONS

Resection of the calcium bar and creation of a new annulus with pericardium provided good clinical results in patients with extensive calcification of the mitral valve.

Complicated mitral valve repairs

The standard of care for mitral regurgitation secondary to degenerative valvular disease is mitral valve repair whenever possible. Mitral valve repair is associated with better left ventricular function preservation, fewer complications, and improved survival as compared with mitral valve replacement. Most of the mitral valve pathology involves the posterior leaflet or annulus and usually can be repaired by using standard valve repair techniques. Difficulties may arise when trying to repair the somewhat uncommon anterior leaflet prolapse or calcified mitral annulus. This article reviews these more complex mitral valve repair techniques and their outcomes.