Ann Thorac Surg 2009;87:1625-1627. doi:10.1016/j.athoracsur.2008.09.014
© 2009 The Society of Thoracic Surgeons
How To Do It
Building a New Annulus: A Technique for Mitral Valve Replacement in Heavily Calcified Annulus
Salvatore Di Stefano, MD, PhDa,*,
Javier López, MD, PhDb,
Santiago Flórez, MD, PhDa,
Juvenal Rey, MDa,
Adolfo Arevalo, MDa,
Alberto San Román, MD, PhDb
a Department of Cardiac Surgery, Heart Institute (ICICOR), University Hospital, Valladolid, Spain
b Department of Cardiology, Heart Institute (ICICOR), University Hospital, Valladolid, Spain
Accepted for publication September 6, 2008.
* Address correspondence to Dr Di Stefano, Heart Institute (ICICOR), Department of Cardiac Surgery, University Hospital of Valladolid, Avda. Ramón y Cajal 3, Valladolid, 47005, Spain (Email: salvadiste{at}gmail.com).
 |
Abstract
|
|---|
We describe the rationale, methodology, and our preliminary experience with a new surgical technique for mitral valve replacement in patients with severe calcification of the mitral annulus in which the conventional techniques can not be applied. In contrast with other procedures published in the literature for these patients, in which the placement of the prosthesis is supra-annular, we plicate both mitral leaflets and the atrial wall creating a new annulus that allows the intra-annular placement of the prosthesis.
|
Introduction
|
|---|
Calcification of the mitral valve annulus is a serious condition, in which an important pathophysiologic factor is the age-related degenerative process. Extensive calcification represents a problem for conservative surgery and also a technical difficulty for implanting prosthetic valves, because occasionally, the calcium does not allow placing direct sutures through the annulus and peri-prosthetic leakage may result. We describe for the first time a new simple surgical technique that allows the intra-annular placement of the prosthesis, creating a new annulus by means of the plication of both mitral leaflets and the atrial wall.
|
Technique
|
|---|
After standard cardiopulmonary bypass and cardioplegic arrest, exposure of the mitral valve was obtained through a standard left atriotomy. In all the cases we realized that the repair of the mitral valve was inappropriate because of the extended calcification. Then we confirmed that direct sutures through the annulus were impossible to perform. We began to pass 2-0 polyester pledgeted mattress sutures between the free edges of the leaflets and the atrial wall, while avoiding passing through the calcified annulus (Fig 1a). Therefore, a new ring was created inside the native annulus (Fig 1b). The direction of the suture is not important and depends on the anatomic difficulty in accordance with the exposure of the valve, so that the placing of the pledget could be intraventricular or intra-atrial (Fig 2). Depending on the extension of the calcification, the technique was performed in the valve in its totality with both leaflets, or only in the calcified part, which is normally the posterior. Despite this, the anterior atrial wall is closely related to the right and left trigones and the inter-trigonal area, and above the annulus it maintains certain motility, it although reduced. Moreover, we compensate this atrial wall reduction of motility by raising the anterior leaflet as much as possible to bring it over to the atrial wall. Given the proximity of the aorta and the aortic valve to this area, special caution must be taken to avoid deep sutures in the inter-trigonal area, which could provoke injury to these structures. Both trigones can be used to anchor and give stability to the sutures.
View larger version (49K):
[in this window]
[in a new window]
|
Fig 1. Standard polyester pledgeted 2-0 U-shaped sutures crossing between (a) the free edges of the leaflet and the atrial wall (b) and the new created ring.
|
|
View larger version (136K):
[in this window]
[in a new window]
|
Fig 2. Left atrial view of the mitral valve with the calcium block that the needle can not pass through (AW = atrial wall; C = calcium; PL = posterior leaflet).
|
|
Subsequently, the sutures were anchored to the sewing ring of the prosthesis and an intra "new-annular" implant was performed. Finally, a visual revision was performed to ensure that no peri-prosthetic leaks were present. If, during this revision, an area seems weaker, an additional suture between the atrial wall and the valvular Teflon (DuPont, Wilmington, DE) can be applied.
|
Comment
|
|---|
Although valve repair is considered the most appropriate surgical technique in mitral valve disease [1, 2], it is not always possible; therefore, the implantation of prosthetic valves is still frequently performed, especially in patients with rheumatic cause in which intense fibrosis and calcification have brought about an irreversible impairment of the native valve. Moreover, according to the traditional technique, albeit on few occasions, an intense calcification of the ring may make a valve implant impossible.
In these cases, several techniques have been proposed to undertake mitral valve replacement, such as enlarging the circumference of the prosthetic valve with a Dacron collar (polyethylene tereph-thalate fiber; Medi-Tech, Boston Scientific Corp, Natick, MA), ring reconstruction with a pericardial patch, and the plication of the left atrial wall, where the prosthesis is directly sutured for an intra-atrial insertion. In some cases, the calcium bar has been excised and a new annulus with pericardium has been created [3–6]. Using these techniques, the implantation of the prosthesis is supra-annular in most cases, which obliges the atrial wall to resist all the hemodynamic stress that can produce a tear of the suture with a consequent perivalvular leak.
From February 2007 to March 2008, this technique was used on 4 patients at our institution, who were all female (mean age, 75 years; range, 67 to 82 years). All patients had mitral rheumatic valve disease (ie, one isolated severe stenosis not amenable for percutaneous valvuloplasty, one severe regurgitation, and both conditions in the remaining 2 patients). A simultaneous aortic valve replacement was performed in 2 patients. They all were in the New York Heart Association functional class III. All of them were treated with oral anticoagulation for more than 10 years; three patients had chronic atrial fibrillation and one had paroxistic atrial fibrillation.
In the preoperative ventriculograms, an intense calcification of the entire mitral annulus was observed in 2 patients (Fig 3), and partial calcification located exclusively in the posterior ring in other 2.
View larger version (167K):
[in this window]
[in a new window]
|
Fig 3. Ventriculogram with the intense calcification of the entire mitral annulus (arrow) (LA = left atrium; LV = left ventricle).
|
|
During surgery, we confirmed the impossibility of repairing the valve and placing direct sutures through the annulus. The calcium extended toward the ventricle and into the myocardium wall, which impeded its resection. For these reasons we decided to use the technique previously described. In three cases we implanted a mechanical prosthesis (two bileaflet Carbomedics No. 25 and a monoleaflet Omnicarbon No. 25; Carbomedics Inc, Austin, TX) and a biological prosthesis (Perimount No. 25; Edwards Lifesciences, Irvine, CA) in the other case.
The transesophageal intraoperative echocardiography confirmed the absence of the perivalvular leak and the postoperative recovery was uneventful in all patients.
After a mean follow-up of 13.5 months (range, 5 to 20 months), all patients were in the New York Heart Association functional class I and prostheses were functioning normally. There was not any echocardiographic paravalvular leakages in any case during follow-up, nor annular dehiscences or other annular pathologies (Fig 4).
View larger version (128K):
[in this window]
[in a new window]
|
Fig 4. Postoperative echocardiography with the prosthesis (arrow) implanted in the new annulus central to the calcium (LA = left atrium; LV = left ventricle; P = prosthesis).
|
|
One limitation of this technique is related to the fact that implanting a prosthesis inside a calcified annulus, then smaller prosthesis sizes are needed, given the reduction of the annular diameter. In our series, a 25-mm diameter prosthesis could be implanted in all our patients.
Obviously, more cases and long-term results are required to demonstrate the effectiveness of this technique. These preliminary results suggest, however, that this type of reconstruction can be performed safely when mitral valve replacement is impossible by means of conventional techniques because of the severe calcification of the mitral annulus, and it is feasible with a minimum risk of technical complications.
|
Acknowledgments
|
|---|
We deeply thank Fernando Zaparaín for designing and drawing Figure 1.
This study was financed in part by the Cooperative Network for Cardiovascular Research (Red Cooperativa de Investigación Cardiovascular, RECAVA) of the Spanish National Institute of Health (Instituto de Salud Carlos III).
|
References
|
|---|
- Jokinen J, Hippelainen M, Pitkanen O, Hartikainen J. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis Ann Thorac Surg 2007;84:451-458.[Abstract/Free Full Text]
- Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement Eur J Cardiothorac Surg 2007;31:267-275.[Abstract/Free Full Text]
- Konstantinov IE, Carter M, Saxena P, et al. Prosthesis replacement in a calcified mitral annulus with reconstruction of the intervalvular fibrous body: the value of an alternative repair Tex Heart Inst J 2006;33:232-234.[Medline]
- Fukada Y, Matsui Y, Sasaki S, Yasuda K. A case of mitral valve replacement with a collar-reinforced prosthetic valve for heavily calcified mitral annulus Ann Thorac Cardiovasc Surg 2005;11:260-263.[Medline]
- Nataf P, Pavie A, Jault F, Bors V, Cabrol C, Gandjbakhch I. Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral annulus Ann Thorac Surg 1994;58:163-167.[Abstract/Free Full Text]
- Iida H, Mochizuki Y, Matsushita Y, Mori H, Yamada Y, Miyoshi S. A valve replacement technique for heavily calcified mitral valve and annulus J Heart Valve Dis 2005;14:209-211.[Medline]
This article has been cited by other articles:
|
|
|
|
 
D. Nezic, A. Knezevic, S. Borovic, and M. Jovic
Mitral valve replacement with posterior transposition of the anterior mitral leaflet which covers and buttresses partially decalcified posterior mitral annular bed
Eur J Cardiothorac Surg,
January 4, 2012;
(2012)
ezr166v1.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
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]
|
|
|
|
|
|
|
A. Nomura, I. Fukuda, K. Daitoku, and K. Fukui
Enucleation of calcium core and in-situ valve replacement for massive posterior mitral annular calcification
Interact CardioVasc Thorac Surg,
April 1, 2011;
12(4):
652 - 654.
[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]
|
|
|
|
|
|
|
S. Di Stefano
Reply
Ann. Thorac. Surg.,
December 1, 2010;
90(6):
2090 - 2091.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
