Ann Thorac Surg 1998;65:1456-1458
© 1998 The Society of Thoracic Surgeons
Case Reports
Mitral Valve Replacement Associated With Massive Left Atrial Calcification
Francesco Santini, MDa,
Pierfranco Peranzoni, MDa,
Alessandro Mazzucco, MDa
a Division of Cardiovascular Surgery, University of Verona Medical School, Verona, Italy
Accepted for publication December 6, 1997.
Address reprint requests to Dr Santini, Division of Cardiovascular Surgery, OCM Borgo Trento, Piazzale Stefani 1, 37126, Verona, Italy
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Abstract
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Massive calcification of the atrial walls is a rare condition that entails important implications for mitral valve operations. Endoatriectomy is the procedure of choice in this situation. A technique of total replacement of the left atrium and mitral valve by means of a valved, T-shaped graft is presented as a possible alternative when a more conventional approach is not feasible.
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Introduction
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Calcification of the left atrium is a relatively common finding in the setting of long-lasting rheumatic valve disease [1, 2]. Massive calcification of the left atrial walls (porcelain atrium), however, is rare and previously has been mostly reported as an incidental radiologic finding [3, 4]. In these patients, routine mitral valve replacement, native or prosthetic, may become challenging in view of the difficulty found in suturing the heavily calcified atrial walls and in the exposure of the mitral valve plane [4–6]. Total endoatriectomy of the left atrium, searching for the best cleavage plane that allows total excision of the thick endothelial layer, is considered the procedure of choice. This technique has been successfully used in our institution on a routine basis.
This report describes a case in which massive and firm calcifications of the left atrium, not manageable by conventional techniques, prompted us to perform total prosthetic replacement of the left atrium and mitral valve "en bloc."
A 61-year-old man in New York Heart Association functional class III and chronic atrial fibrillation was referred to our hospital for replacement of disfunctioning aortic and mitral mechanical prostheses (Starr-Edwards) implanted 28 years before in another institution. Past medical history revealed long-standing rheumatic valve disease. On admission, chest roentgenography showed cardiomegaly (cardiothoracic ratio = 0.8) and massive calcification of the left atrium (Fig 1). Cardiac catheterization and echocardiography showed a moderately depressed ventricular function (ejection fraction = 0.38; left ventricular end-diastolic volume index = 65 mL/m2) and a peak gradient across the aortic and mitral prostheses of 63 and 23 mm Hg, respectively (mean, 40 and 13 mm Hg, respectively). There was moderate aortic and mitral valve regurgitation (perivalvular leaks), a moderate increase in pulmonary arterial pressure (54 mm Hg, systolic) and moderate tricuspid incompetence. The coronary arteries were normal.
Through a median resternotomy, the ascending aorta and both venae cavae were cannulated with angled cannulas and cardiopulmonary bypass was established. After moderate systemic hypothermia (28°C) was reached, the ascending aorta was cross-clamped and, while the right pulmonary veins were vented, cold blood cardioplegic solution was administered both antegradely and retrogradely. After removal of the aortic prosthesis, an attempt was made to enter the left atrium through the interatrial groove. This incision, however, proved not feasible because of extensive, thick calcifications. A transseptal approach was therefore undertaken, which revealed the presence of a similarly heavily calcified septum and left atrial roof. A search for a cleavage plane to achieve total removal of the calcified endocardium was initiated, in an attempt to perform a total endoatriectomy. However, the full thickness of the atrial wall appeared calcified, thus not allowing for any layered dissection. Therefore, the decision was taken to radically resect the entire left atrial wall, from the pulmonary veins down to the mitral valve annulus, leaving in place a bilateral cuff of pulmonary venous tissue containing the pulmonary venous orifices. After removal of the old Starr-Edwards prosthesis, a no. 29 Carbomedics prosthetic valve (Sulzer Carbomedics, Austin, TX) was implanted using 2-0 Ti-cron (Cyanamid of Great Britain, Ltd, Gosport, Great Britain) interrupted sutures reinforced with pledgets. A T conduit was then constructed connecting a first vascular graft to the pulmonary vein cuffs, and a second graft between the former and the prosthetic mitral Teflon ring, in a T fashion (Fig 2). The operation was then completed with reconstruction of the interatrial septum with bovine pericardium, aortic valve replacement with a no. 25 Carbomedics prosthesis, and tricuspid annuloplasty according to the De Vega technique. After aortic cross-clamp removal, the heart resumed atrial fibrillation (paced VVI with temporary wires), and weaning off cardiopulmonary bypass was achieved with epinephrine (0.08 Y/Kg/min) and dopamine (5 µg · kg-1 · min-1).
Over the following 24 hours the patient gained satisfactory hemodynamic stability but required prolonged ventilatory support. He was extubated after 6 days and discharged in good clinical conditions on postoperative day 19. One year after the operation, he is in New York Heart Association functional class II; follow-up echocardiography showed normally functioning prostheses with only mildly diminished left ventricular contractility. A computed tomographic scan disclosed a successful anatomic reconstruction of the new prosthetic left atrium by means of a T-shaped conduit with no evidence of intracavitary thrombosis (Fig 3).
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Fig 3. Chest computed tomographic scan showing the T graft (arrows) connecting the pulmonary vein cuffs to the mitral annulus, with no evidence of intracavitary thrombosis.
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Comment
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Massive calcification of the left atrium is an uncommon complication of long-standing rheumatic valvular disease and is more often observed in patients with a previous operation on the mitral valve [1–4]. It entails two major surgical problems: (1) a complex approach to the left atrium and mitral valve annulus and (2) hemostatic closure of the atriotomy [4]. In this situation, it is common practice to approach the left atrium through the right atrium and interatrial septum (Dubost’s incision), which is often free from calcification, finding the best cleavage plane to remove the entire calcified "cortex" (total endoatriectomy) [4–6].
In the case presented herein, a complete left atrial endoatriectomy was initially undertaken but soon abandoned because of the full-thickness calcific degeneration of the atrial wall and absence of a cleavage plane. The left atrium was therefore removed en bloc, leaving only two small pulmonary vein cuffs free of calcification. A wide T graft was then constructed and the mitral valve replaced according to the standard technique. The postoperative presence of a noncompliant left atrial reservoir in this patient appeared well tolerated hemodynamically. Indeed, this variable did not represent a substantial change compared with the preoperative status (massively calcified stiff left atrium).
In conclusion, although total endoatriectomy of a calcified left atrium remains the procedure of choice, the possibility of performing total prosthetic replacement of the left atrium and mitral valve en bloc in complicated cases should be kept in the surgeon’s armamentarium as an acceptable solution for a potentially dreadful condition.
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References
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- Oppenheimer B.S. Calcification and osteogenic change of the left auricle in a case of auricular fibrillation. Proc NY Pathol Soc 1912;12:213-215.
- Leonard J.J., Katz S., Nelson D. Calcification of the left atrium: its anatomic location, diagnostic significance and roentgenologic demonstration. N Engl J Med 1957;256:629-633.[Medline]
- In: Shanks S.C., Kerley P., Twining E.W., eds. . A textbook of x-ray diagnosis by British authors. London: H.K. Lewis & Co, 1938:47-50.
- Vallejo J.L., Merino C., Gonzalez-Santos J.M., et al. Massive calcification of the left atrium: surgical implications. Ann Thorac Surg 1995;60:1226-1229.[Abstract/Free Full Text]
- Harthorne J.W., Selzer R.A., Austen W.G. Left atrial calcification. Review of literature and proposed management. Circulation 1966;34:198-210.[Abstract/Free Full Text]
- Ruvolo G., Greco E., Speziale G., Mercogliano D., Marino B. "Mold-like" calcification of the left atrium and of the pulmonary veins. Total endoatriectomy in a patient undergoing mitral valve replacement. Eur J Cardiothorac Surg 1994;8:54-55.[Abstract/Free Full Text]
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Abstract
Introduction
