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Ann Thorac Surg 1998;66:2157-2158
© 1998 The Society of Thoracic Surgeons

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Correspondence

Left atrial wall plication for valve replacement in extensively calcified posterior mitral annulus

^a Division of Cardiac Surgery, Scientific Institute H.S. Raffaele, Via Olgettina, 60-20131, Milan, Italy

To the Editor

Conventional suturing techniques for mitral valve replacement need a pliable annular tissue that in some instances can be obtained only after removal of annular calcium deposits. However, extensive calcium debridement is a dangerous procedure that exposes the patient to the risk of thromboembolic events, circumflex artery injury, and, of main importance, excessive left ventricular posterior wall thinning with the subsequent potential for free wall rupture. Obviously these complications are more likely to occur when there is massive calcification of the posterior mitral leaflet and annulus [1]. Therefore, on one hand calcifications should be left untouched and on the other hand it is necessary to identify an adequately resistant and easily perforable tissue to perform the suture of the prosthesis to the annulus.

We read with great interest the paper by Ruvolo and colleagues published in the "How to Do It" section of The Annals that dealt with the problem of heavy annular calcifications complicating mitral valve surgery [2]. Unfortunately, it is possible that the technique of the "patch-glue annular reconstruction" described by the authors can not be performed because the posterior leaflet diffusely involved by the calcification process can not be removed. In March 1998 we operated on a 78-year-old woman with this type of complication.

The patient was admitted to our institute with a diagnosis of degenerative aortic valve disease and mitral valve disease (mitral valve stenosis, area 0.8 cm², moderate mitral regurgitation, and moderate pulmonary hypertension), history of rheumatic disease, and NYHA class III–IV. Two-dimensional transthoracic echocardiography and cardiac catheterization (Fig 1) revealed massive calcification of the posterior mitral leaflet extending to the posterior portion of the annulus, the left atrial, and the left ventricular wall. Aortic and mitral valve replacement was scheduled and the patient underwent an operation. We made a standard median full sternotomy and cannulated the ascending aorta and both venae cavae, establishing normothermic cardiopulmonary bypass. Myocardial protection consisted of intermittent normothermic blood cardioplegia. A left atriotomy was performed. Massive calcification of the posterior leaflet was extended to the posterior portion of the mitral annulus, with calcium bars invading the left atrial as well as the left ventricular wall. The blocks of calcium were also appreciable from the external of the heart because they protruded into the atrioventricular groove. We decided to implant a pericardial prosthesis (Carpentier-Edwards) in the supra-annular position. The anterior mitral leaflet was removed, and U-shaped stitches (2-0 Ti-Cron) reinforced with pledgets of Teflon (PTFE Ethicon SpA 00040, Rome, Italy) on the ventricular side were passed over. At this time we sized the area between the anterior portion of the mitral annulus and the free edge of the posterior mitral leaflet, and choose a prosthesis no. 25. Because the body of the posterior leaflet was too calcified and stitches could not be passed over it, the sutures went through the edge of the posterior leaflet (that was too thin to be reliable) and were reinforced with a plication of the left atrial wall above the posterior annulus (Fig 2). The aortic valve was thus replaced by means of a pericardial Carpentier-Edwards prosthesis no. 21. The technique here described is easy to perform and allowed us to implant safely and expeditiously a prosthesis in a situation that could be considered hardly operable.

View larger version (28K): [in this window] [in a new window]   Fig 1. Implantation of the prosthesis suturing the remnant of the posterior mitral leaflet to the left atrial wall plication. (A) Sutures through the remnant of the posterior mitral leaflet and through the left atrial wall plication. (B) Sutures tied allowing the implantation of the prosthesis.

1. Coselli J.S., Crawford E.S. Calcified mitral annulus: prosthesis insertion. Ann Thorac Surg 1988;46:584-586.[Abstract/Free Full Text]
2. Ruvolo G., Speziale G., Voci P., Marino B. Patch-glue annular reconstruction for mitral valve replacement in severely calcified mitral annulus. Ann Thorac Surg 1997;63:570-571.[Abstract/Free Full Text]

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				J. Gualis, M. Castano, J. Gomez-Plana, C. Martin, A. de Miguel, and A. de Diego Mitral valve prosthesis implanted in atrial wall over huge calcified annulus Asian Cardiovasc Thorac Ann, June 1, 2011; 19(3-4): 279 - 280. [Abstract] [Full Text] [PDF]

				J. Gualis, M. Castano, J. Gomez-Plana, C. Martin, J. M. Martinez, A. De Miguel, and A. De Diego Mitral Valve Replacement in Heavily Calcified Annulus Ann. Thorac. Surg., December 1, 2010; 90(6): 2090 - 2090. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michele Triggiani Ottavio Alfieri Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Triggiani, M. Articles by Alfieri, O. Search for Related Content PubMed PubMed Citation Articles by Triggiani, M. Articles by Alfieri, O.