Extensive Mitral Annular Calcification Research Articles

Discussion to: Contemporary surgical techniques for mitral valve replacement in extensive mitral annular calcification

Discussion to: Contemporary surgical techniques for mitral valve replacement in extensive mitral annular calcification

Contemporary surgical techniques for mitral valve replacement in extensive mitral annular calcification

ObjectivesMitral annular calcification remains a formidable lesion in cardiac surgery with significant perioperative morbidity and mortality, particularly when en bloc annular decalcification is implemented. Respect strategies and hybrid approaches have provided safe alternatives. We report the short-term results of our institution's experience with mitral valve replacement in patients with extensive annular calcification. MethodsThis is a retrospective review of 72 consecutive patients with extensive annular calcification who underwent open surgical mitral valve replacement from January 1, 2013, to September 31, 2022. Degree of annular calcification was graded as partial, horseshoe, or circumferential. We excluded patients with calcification involving less than one-third of the annulus and patients with rheumatic heart disease. ResultsMean patient age was 71.6 ± 10.9 years, and 50 (69.4%) were female. There were 51 patients (70.8%) with New York Heart Association class 3 or greater and 47 patients (65.3%) with pulmonary hypertension. There were 41 patients (56.9%) with partial, 12 patients (16.7%) with horseshoe, and 19 patients (26.4%) with circumferential calcification. Fifty-six patients (77.8%) underwent conventional valve replacement. Sixteen patients underwent a hybrid procedure using balloon-expandable devices. Concomitant procedures were performed in 61 patients (84.7%). In-hospital mortality and 1-year survival were 3.57% and 82.8% in the standard valve replacement cohort and 25.0% and 54.7% in the hybrid cohort, respectively. ConclusionsConventional mitral valve replacement using respect strategies is safe and associated with good outcomes in patients with extensive annular calcification. Hybrid approaches using novel devices should remain as a bailout in select patients because of higher perioperative risks and poor short-term outcomes.

Sex Differences in Extensive Mitral Annular Calcification With Associated Mitral Valve Dysfunction

Mitral annular calcification (MAC)-related mitral valve (MV) dysfunction is an increasingly recognized entity, which confers a high burden of morbidity and mortality. Although more common among women, there is a paucity of data regarding how the phenotype of MAC and the associated adverse clinical implications may differ between women and men. A total of 3,524 patients with extensive MAC and significant MAC-related MV dysfunction (i.e., transmitral gradient ≥3mm Hg) were retrospectively analyzed from a large institutional database, with the goal of defining gender differences in clinical and echocardiographic characteristics and the prognostic importance of MAC-related MV dysfunction. We stratified patients into low- (3 to 5mm Hg), moderate- (5 to 10mm Hg), and high- (≥10mm Hg) gradient groups and analyzed the gender differences in phenotype and outcome. The primary outcome was all-cause mortality, assessed using adjusted Cox regression models. Women represented the majority (67%) of subjects, were older (79.3 ± 10.4 vs 75.5 ± 10.9years, p <0.001) and had a lower burden of cardiovascular co-morbidities than men. Women had higher transmitral gradients (5.7 ± 2.7 vs 5.3 ± 2.6mm Hg, p <0.001), more concentric hypertrophy (49% vs 33%), and more mitral regurgitation. The median survival was 3.4years (95% confidence interval 3.0 to 3.6) among women and 3.0years (95% confidence interval 2.6 to 4.5) among men. The adjusted survival was worse among men, and the prognostic impact of the transmitral gradient did not differ overall by gender. In conclusion, we describe important gender differences among patients with MAC-related MV dysfunction and show worse adjusted survival among men; although, the adverse prognostic impact of the transmitral gradient was similar between men and women.

Handling Extensive Mitral Annular Calcification via a Minimally Invasive Right Mini-Thoracotomy Approach

Mitral annular calcification is a chronic and degenerative process of the fibrous base of the mitral valve. Surgical management of mitral valve dysfunction with severe annular calcification remains technically demanding and, to date, the preferred approach is still a standard full sternotomy. We aimed to analyze and report our experience with mitral valve surgery addressing annular calcification via the minimally invasive approach through a right mini-thoracotomy. Data of patients with mitral valve disease and underlying annular calcification undergoing minimally invasive surgery from 2018 to 2022 were prospectively collected and retrospectively analyzed. The severity of mitral annular calcification was categorized with an angio-computerized tomography scan analysis as mild, moderate or severe according to calcium thickness, calcium distribution, and trigone and leaflet involvement using the Mitral Annular Calcification Computerized Tomography-score. During the study period, 27 patients with mitral valve disease and associated mitral annular calcification were enrolled. The most common etiology was advanced Barlow’s disease, which was encountered in 18 cases (67%). Mitral valve replacement was performed in 21 patients (78%). No intraoperative death, atrioventricular disruption, or circumflex coronary artery injury occurred. Conversion to sternotomy was necessary in a single case. Residual moderate periprosthetic leak requiring early reoperation and permanent heart block mandating permanent pacemaker implantation were reported in one and in three patients, respectively. No cases of stroke were reported. Two patients died, accounting for a 7.4% perioperative mortality. At a median follow-up of 9 months, one patient had residual moderate mitral regurgitation, whereas two patients required short-term reoperation and prosthetic valve (re)replacement. Minimally invasive mitral valve surgery via right mini-thoracotomy should be considered an and effective approach to be indicated also in patients with mild-to-severe mitral annular calcification. Routine angio-computerized tomography scan during work-up is a mandatory step to stratify the anatomical extension and severity of the mitral annular calcification.

Hybrid Surgery for Severe Mitral Valve Calcification: Limitations and Caveats for an Open Transcatheter Approach.

Background and Objectives: Mitral stenosis with extensive mitral annular calcification (MAC) remains surgically challenging in respect to clinical outcome. Prolonged surgery time with imminent ventricular rupture and systolic anterior motion can be considered as a complex of causal factors. The aim of our alternative hybrid approach was to reduce the risk of annual rupture and paravalvular leaks and to avoid obstruction of the outflow tract. A review of the current literature was also carried out. Materials and Methods: Six female patients (mean age 76 ± 9 years) with severe mitral valve stenosis and severely calcified annulus underwent an open implantation of an Edwards Sapien 3 prosthesis on cardiopulmonary bypass. Our hybrid approach involved resection of the anterior mitral leaflet, placement of anchor sutures and the deployment of a balloon expanded prosthesis under visual control. Concomitant procedures were carried out in three patients. Results: The mean duration of cross-clamping was 95 ± 31 min and cardiopulmonary bypass was 137 ± 60 min. The perioperative TEE showed in three patients an inconspicuous, heart valve-typical gradient on all implanted prostheses and a clinically irrelevant paravalvular leakage occurred in the anterior annulus. In the left ventricular outflow tract, mild to moderately elevated gradients were recorded. No adverse cerebrovascular events and pacemaker implantations were observed. All but one patient survived to discharge. Survival at one year was 83.3%. Conclusions: This “off label” implantation of the Edwards Sapien 3 prosthesis may be considered as a suitable bail-out approach for patients at high-risk for mitral valve surgery or deemed inoperable due to extensive MAC.

Early Outcomes for Surgical Minimally Invasive SAPIEN 3 Transcatheter Mitral Valve Replacement

Limited surgical options are available for patients with extensive mitral annular calcification. Several reports have shown the feasibility of surgical mitral valve replacement (MVR) using a transcatheter aortic valve in the mitral position (MVR-TAVR). This study reviewed 30-day and 1-year outcomes of a minimally invasive approach for MVR-TAVR. Between 2017 and 2019, 16 patients underwent MVR-TAVR under direct vision. Primary end points included overall survival, technical success, and effectiveness. Secondary end points included valve and cardiac hemodynamics postoperatively and during follow up. The 16 patients (69% female) were 53 to 88 years of age (average, 77 ± 9 years). Comorbidities on presentation were as follows: 31% (5 of 16) were reoperative procedures; 13% (3 of 16) of patients had right ventricular dysfunction, 31% (5 of 16) had severe pulmonary hypertension, and 20% (3 of 16) had chronic kidney disease. Isolated MVR-TAVR was performed on 69% (11 of 16) of patients, with a cross-clamp (58%; 7 of 12) or on a fibrillating heart (42%; 5 of 12), whereas concomitant MVR-TAVR was performed in 31% (5 of 16) of patients with a cross-clamp. At follow-up, the estimated 30-day mortality rate was 12.5%, and the 1-year mortality rate was 36.2%. A moderate postoperative paravalvular leak (PVL) was evident immediately in 1 patient, and a severe PVL was noted after 30-day follow-up in another. In addition, 1 patient had mild left ventricular outflow tract obstruction, and another had moderate mitral valve stenosis. At 1-year follow-up, there were no changes in the mild PVL and moderate stenosis identified postoperatively. Minithoracotomy MVR-TAVR is an acceptable alternative to conventional and transcatheter MVR in patients with mitral valve disease and extensive mitral annular calcification.

Advanced experience allows robotic mitral valve repair in the presence of extensive mitral annular calcification

ObjectiveMitral annular calcification is underdiagnosed in patients with mitral regurgitation. After excision, it may require reconstruction of the atrioventricular groove and decreases the probability of valve repair. We reviewed the safety and efficacy of totally endoscopic robotic mitral valve repair in the presence of mitral annular calcification, with an emphasis on pathology and repair techniques. MethodsBetween May 2011 and August 2017, the same 2-surgeon team attempted totally endoscopic robotic mitral valve repair in 64 mitral annular calcification cases, accounting for 12.8% of our experience. Mitral annular calcification associated with a calcified posterior leaflet was not considered for totally endoscopic robotic mitral valve repair. When possible, the mitral annular calcification was excised en bloc using electrocautery, the posterior leaflet separated from the mitral annular calcification and spared, the atrioventricular groove was reconstructed, the posterior leaflet was reattached to the neoannulus, and the repair was completed with annuloplasty. ResultsThe median age of patients was 65 years, with 21 (32.8%) aged less than 60 years, and 34 (53.1%) were women. The etiology was Barlow's disease in 54 patients (84%). Repair was converted to replacement in 2 patients (3.1%). Cryoablation was performed in 8 patients (12.5%), hybrid percutaneous coronary intervention was performed in 5 patients (7.8%), and tricuspid annuloplasty was performed in 2 patients (3.1%). Median aortic occlusion was 122 minutes, excluding cases with concomitant tricuspid repair. Thirty-three patients (52%) were extubated in the operating room. The median length of stay was 4 days. Residual mitral regurgitation on discharge transthoracic echocardiogram was none to mild in all patients. None of the patients had a perioperative stroke or needed a pacemaker. Thirty-day mortality was 2 (3.1%). ConclusionsMitral annular calcification is present in a significant percentage of patients with mitral regurgitation, especially in Barlow's disease, including younger patients. By using a variety of repair techniques, totally endoscopic robotic mitral valve repair can be performed safely and effectively in most mitral annular calcification cases with a noncalcified posterior leaflet.

Mitral Valve Surgery in Patients With Extensive Mitral Annular Calcification: Outcomes and Long-Term Follow-Up

Aim: To examine the early and late outcomes of patients with extensive mitral annular calcification undergoing mitral valve (MV) surgery.

Minimally Invasive Direct Access Balloon-Expandable Transcatheter Mitral Valve Replacement for Extensive Mitral Annular Calcification after Transcatheter Aortic Valve Replacement

Minimally Invasive Direct Access Balloon-Expandable Transcatheter Mitral Valve Replacement for Extensive Mitral Annular Calcification after Transcatheter Aortic Valve Replacement

Surgical Mitral Valve Replacement With Edwards Sapien Valve- A First

An extensive mitral annular calcification presents a formidable technical challenge during mitral valve surgeries. A 68-year-old female presented to our hospital for surgical treatment of severe mitral stenosis with heavily calcified annulus. She had a background of chemotherapy and radiotherapy for Hodgkin's lymphoma 12 years earlier. In view of heavy and extensive calcification of mitral annulus and subvalvular apparatus, a mitral valve replacement (MVR) using standard prosthetic valve was not possible and she underwent surgical replacement with a transcatheter aortic valve- an Edwards Sapien XT valve. She was not suitable for percutaneous MVR because of heavily calcified anterior mitral leaflet. To our knowledge, this is the first published report of surgical MVR with Edwards Sapien valve. Keywords: Extensive mitral annular calcification; Mitral valve replacement; Trascatheter aortic valve; Edwards Sapien valve

Direct Access Implantation of a Melody Valve in Native Mitral Valve: A Hybrid Approach in the Presence of Extensive Mitral Annular Calcification

A 76-year-old woman presented with congestive heart failure. Transthoracic echocardiogram showed severe mitral regurgitation and moderate mitral stenosis with a mean gradient of 8 mm Hg as a result of inflow obstruction in the setting of extensive mitral annular calcium with severe tricuspid regurgitation and severe pulmonary hypertension. The preoperative coronary angiogram and the computed tomography scan showed horseshoe-shaped severe mitral annular calcium (Figs 1A [arrows], 1B). Intraoperative transesophageal echocardiogram confirmed the mitral annular calcium (Fig 1D), and there was severe mitral regurgitation (Fig 1C).

A case of mobile mitral annular mass

Mitral annular calcification is a chronic, degenerative process of the mitral valve fibrous ring, primarily involving the posterior annulus. This report presented a case of mitral annular calcification with mobile components which was found incidentally during TTE. The echocardiographic differential diagnosis of a mass includes thrombus, vegetation, primary or secondary cardiac tumor and extensive mitral annular calcification with mobile components. A calcified, mobile mass attached to the posterior mitral annulus should raise the suspicion of extensive mitral annular calcification. Serial echocardiograms in our patient documented that these mobile elements can resolve rapidly. The optimal treatment or clinical approach to this clinical condition remains to be established.

Partial Translocation Mitral Valve Replacement with Autologous Pericardial Patch Reinforcement of Ventricularized Left Atrial Wall for Severe Annular Calcification Extending to the Left Ventricle

We describe a technique of partial translocation with an autologous pericardial patch reinforcement of the left atrial wall in patients with extensive mitral annular calcification (MAC) who require mitral valve replacement.

Paraprosthetic leak closure 28 years after mitral caged-ball Starr-Edwards implantation

In this case report, we present a patient 28 years after mitral valve replacement with the Starr-Edwards prosthesis complicated by periprosthetic leak with severe aortic stenosis and moderate tricuspid regurgitation. We successfully repaired the periprosthetic regurgitation in a patient with extensive mitral annular calcification, without replacement of the valve. No apparent structural deterioration on the caged-ball valve was found. Moreover, aortic valve replacement and tricuspid annuloplasty were performed. One month after reoperation, the patient remained stable with improved clinical status and without any evidence for further paravalvular leak.

Cardiac Computed Tomography Facilitates Operative Planning in Patients With Mitral Calcification

Extensive mitral annular calcification (MAC) can represent a significant surgical challenge. We use three illustrative examples to describe our early experience with electrocardiogram-gated cardiac computed tomography (CT) as a preoperative tool to localize MAC and to predict requisite surgical techniques. In all three cases, cardiac CT accurately delineated the location and extent of calcification compared with intraoperative findings, and in each case, it assisted in predicting the required operation (avoidance vs resection of calcification; need for annular reconstruction). All 3 patients experienced an uneventful postoperative course with no evidence of paravalvular leak on follow-up echocardiography.

Repeated mitral valve replacement in a patient with extensive annular calcification

BackgroundMitral valve replacement in the presence of severe annular calcification is a technical challenge.Case reportA 47-year-old lady who had undergone mitral and aortic valve replacement for rheumatic disease 27 years before presented with dyspnea. At reoperation, extensive mitral annular calcification was hindering the disc motion of the Starr-Edwards mitral prosthesis. The old prosthesis was removed and a St Jude Medical mechanical valve was implanted after thorough annular debridement. Postoperatively the patient developed paravalvular leak and hemolytic anemia, subsequently undergoing reoperation three days later. The mitral valve was replaced with an Edwards MIRA valve, with a bulkier sewing cuff, after more aggressive annular debridement. Although initially there was no paravalvular leak, it recurred five days later. The patient also developed a small cerebral hemorrhage. As the paravalvular leak and hemolytic anemia gradually worsened, the patient underwent reoperation 14 days later. A Carpentier-Edwards bioprosthetic valve with equine pericardial patches, one to cover the debrided calcified annulus, another as a collar around the prosthesis, was used to eliminate paravalvular leak. At 7 years postoperatively the patient is doing well without any evidence of paravalvular leak or structural valve deterioration.ConclusionMitral valve replacement using a bioprosthesis with equine pericardial patches was useful to overcome recurrent paravalvular leak due to severe mitral annular calcification.

621 ECG-gated Cardiac CT facilitates operative planning in patients with Extensive Mitral Annular Calcification

Extensive Mitral Annular Calcification (MAC) can represent a significant surgical challenge. Although techniques for complete decalcification are described, some surgeons prefer to remove MAC only when necessary. Preoperative identification of the precise implications of MAC has been difficult. We describe our early experience with ECG-Gated Cardiac CT as a preoperative tool to identify the extent of MAC, and to predict requisite surgical techniques. Chart review was performed to identify all patients with ECG-gated cardiac CT for evaluation of extensive MAC, prior to isolated MVR by a single surgeon between April 2010-April 2011. All CTs were reviewed with a thoracic radiologist pre-operatively. Hospital charts were reviewed retrospectively to determine findings and outcomes. Three patients with pre-operative ECG-gated Cardiac CT for extensive MAC underwent successful MVR, with an uneventful post-operative course, and no evidence of paravalvular leak on follow-up echocardiography. CASE 1: 58-year-old woman with bileaflet prolapse, severe MR, and significant MAC on cardiac catheterization. Cardiac CT identified invasive MAC from P1 to mid-P3, but with an adequate orifice to accommodate a prosthesis. Further, adequate mitral leaflet was present adjacent to the MAC. CT findings predicted that no resection of MAC would be necessary. At surgery, interrupted sutures for MVR were placed through supple leaflet in the region of MAC which was otherwise left undisturbed. CASE 2: 80-year-old woman with symptomatic MS and MR, and nearly circumferential MAC on cardiac catheterization. Cardiac CT confirmed extensive MAC, but with an adequate orifice to accommodate a prosthesis. Anterolaterally, there was only diminutive residual leaflet overlying the MAC. CT findings predicted that resection of MAC and annular reconstruction would be required for the placement of valve sutures. At surgery, full anterolateral decalcification and annular reconstruction was required for successful MVR. CASE 3: 58-year-old woman with fatigue on exertion, and echocardiography demonstrating mild-moderate MR, moderate MS, elevated PA pressure, and severe MAC. Cardiac CT identified extensive circumferential MAC, deeply invasive into the myocardium to the level of the papillary muscles. The residual mitral orifice was insufficient to accept a prosthesis. CT findings predicted that extensive decalcification and reconstruction would be required. Anticipating a high-risk MVR, surgery was delayed until symptoms justified the predicted risk. At eventual surgery, complete anterior decalcification, partial posterior decalcification, and bovine pericardial reconstruction were required for MVR. ECG-gated Cardiac CT is a useful tool to predict requisite operative MVR technique in patients with extensive MAC.

Edge-to-edge mitral valve repair for anterior leaflet prolapse associated with extensive calcification of the mitral annulus: Report of a case

Extensive mitral annular calcification remains a technical challenge in mitral valve surgery. Decalcification and reconstruction of the mitral annulus is an established technique, but it is time consuming and technically demanding. This report presents the case of an 88-year-old diabetic female patient in whom edge-to-edge repair was completed quickly, with good early results thus being obtained.

Use of the Seldinger Type Movement Over a J-Shaped Stylet for Left Ventricular Vent Insertion

Access through the right superior pulmonary vein is a commonly used route for left ventricular vent insertion. Complex reshaping of the stylet and vent into a certain position or external guidance do not guarantee successful placement. In this article we describe a modified technique where the stylet sets up the position to allow consistent atraumatic advancement of the catheter across the mitral valve.

Extensive myocardial and mitral annular calcification leading to mitral regurgitation and restrictive cardiomyopathy: An unusual case of caseous calcification of the mitral annulus

A 62-year-old man with polymyalgia rheumatica and chronic atrial fibrillation with prior atrioventricular node ablation and pacemaker implantation presented with progressive exertional dyspnea. Transthoracic echocardiography showed restrictive filling as well as extensive calcification of the mitral annulus and severe mitral regurgitation from a restricted posterior leaflet. A round, hyperechoic lesion with central lucency was noted within the interventricular septum along with calcification of the basal anterior, lateral, and posterior segments of the left ventricle (Fig. 1; Supplementary Videos 1–2) unchanged since previous echocardiogram 2 years before. An electrocardiographic-gated dual-source cardiac CT (Somatom Definition Siemens Medical Solutions, Forchheim, Germany) confirmed extensive mitral annular calcification and diffuse, near-transmural involvement of a heterogenous peripherally calcified lesion (at largest 5.3×3.3 cm) within the myocardium (Fig. 2). This was more extensive than noted by echocardiography. These findings are consistent with an atypical caseous mitral annular calcification extending along the fibrous skeleton of the heart. Surgical repair was offered, but the patient elected for conservative management. Figure 2Cardiac CT images in short axis further delineating areas of diffuse involvement within the left ventricular myocardium. View Large Image Figure Viewer Download Hi-res image