Prior Mitral Valve Replacement Research Articles

Transcatheter heart valve interventions for patients with rheumatic heart disease.

Rheumatic heart disease [RHD] is the most prevalent cause of valvular heart disease in the world, outstripping degenerative aortic stenosis numbers fourfold. Despite this, global resources are firmly aimed at improving the management of degenerative disease. Reasons remain complex and include lack of resources, expertise, and overall access to valve interventions in developing nations, where RHD is most prevalent. Is it time to consider less invasive alternatives to conventional valve surgery? Several anatomical and pathological differences exist between degenerative and rheumatic valves, including percutaneous valve landing zones. These are poorly documented and may require dedicated solutions when considering percutaneous intervention. Percutaneous balloon mitral valvuloplasty (PBMV) is the treatment of choice for severe mitral stenosis (MS) but is reserved for patients with suitable valve anatomy without significant mitral regurgitation (MR), the commonest lesion in RHD. Valvuloplasty also rarely offers a durable solution for patients with rheumatic aortic stenosis (AS) or aortic regurgitation (AR). MR and AR pose unique challenges to successful transcatheter valve implantation as landing zone calcification, so central in docking transcatheter aortic valves in degenerative AS, is often lacking. Surgery in young RHD patients requires mechanical prostheses for durability but morbidity and mortality from both thrombotic complications and bleeding on Warfarin remains excessively high. Also, redo surgery rates are high for progression of aortic valve disease in patients with prior mitral valve replacement (MVR). Transcatheter treatments may offer a solution to anticoagulation problems and address reoperation in patients with prior MVR or failing ventricles, but would have to be tailored to the rheumatic environment. The high prevalence of MR and AR, lack of calcification and other unique anatomical challenges remain. Improvements in tissue durability, the development of novel synthetic valve leaflet materials, dedicated delivery systems and docking stations or anchoring systems to securely land the transcatheter devices, would all require attention. We review the epidemiology of RHD and discuss anatomical differences between rheumatic valves and other pathologies with a view to transcatheter solutions. The shortcomings of current RHD management, including current transcatheter treatments, will be discussed and finally we look at future developments in the field.

Acute and long-term success of left atrial anterior line and mitral isthmus line ablation in patients after mitral valve surgery

Abstract Background Perimitral flutter and atrial fibrillation may occur in patients with prior surgical mitral valve (MV) repair or replacement and can be challenging for percutaneous catheter ablation. Objective This study sought to determine the feasibility, acute success and durability of catheter ablation of atrial fibrillation or atrial tachycardia by way of a mitral isthmus line (MIL) or an anterior line (AL). Methods A total of 81 patients (49 males, mean age 62±11 years) with prior MV replacement (n=30) or repair (n=51) underwent creation of a MIL (n=34) and/or an AL (n=72). Control group patients without prior surgery were matched 1:1 with the valve group (MIL, n=34; AL, n=72). Results Acute bidirectional block of the MIL was successfully achieved in 24/34 cases and of the AL in 64/72 patients with prior MV surgery. In the control group, acute bidirectional block was achieved in 31/34 MIL patients and 65/72 AL patients. In terms of durability, the MIL valve subgroup showed the poorest results (probability of long-term failure 2.224, as opposed to 0.605 in the MIL control subgroup; hazard ratio [HR]=0.27, 95% confidence interval [CI], 0.11–0.65; p=0.004). In the AL subgroups, long-term outcomes were similar (probability of failure in AL valve subgroup 0.844 vs. AL control subgroup 1.03; HR=1.22, 95% CI, 0.66–2.26; p=0.523). Conclusions Percutaneous creation of MIL and AL is feasible and safe in patients with prior MV replacement/repair. Because of poor long-term outcomes, MIL creation appears not advisable in patient with prior MV surgery. Funding Acknowledgement Type of funding sources: None.

Acute and long-term success of left atrial anterior line and mitral isthmus line ablation in patients after mitral valve surgery.

Perimitral flutter and atrial fibrillation may occur in patients with prior surgical mitral valve (MV) repair or replacement and can be challenging for percutaneous catheter ablation. This study sought to determine the feasibility, acute success and durability of catheter ablation of atrial fibrillation or atrial tachycardia by way of a mitral isthmus line (MIL) or an anterior line (AL). A total of 81 patients (49 males, mean age 62±11 years) with prior MV replacement (n=30) or reconstruction (n=51) underwent creation of a MIL (34) and/or an AL (72). Acute bidirectional block of the MIL was successfully achieved in 24/34 cases and of the AL in 64/72 patients. Patients of the control group without prior MV surgery were matched 1:1 with the valve group. In the AL control subgroup, acute bidirectional block was achieved in 65/72 patients. Acute blockage in the MIL control subgroup could be achieved in 31/34 patients. The MIL valve subgroup showed the worst results in terms of durability, whereas a similar trend emerged in the control group and the AL valve subgroup (probability of failure in MIL valve subgroup 2.224vs. MIL control subgroup 0.605 [Hazard Ratio (HR)=0.27, 95% confidence interval (CI), 0.11-0.65), P=.004]; probability of failure in AL valve subgroup 0.844vs. AL control subgroup 1.03 [HR=1.22 (95% CI, 0.66-2.26), P=.523]). Percutaneous creation of MIL and AL is feasible and safe in patients with prior MV replacement/repair and associated with moderate acute and long-term success rates to achieve bidirectional block.

Bioprosthesis in the Mitral Position: Bovine Pericardial versus Porcine Xenograft.

BackgroundWhile the use of bioprosthetic valves for mitral valve replacement (MVR) is increasing, very few studies have compared bovine pericardial and porcine valves in the mitral position to help guide bioprosthetic selection.MethodsIn the present study, patients who underwent MVR using bovine pericardial valves were compared with those who underwent MVR with porcine bioprostheses between January 1996 and July 2018. Those with prior MVR, infective endocarditis, congenital mitral valve disease, or ischemic mitral regurgitation were excluded. The primary outcomes were structural valve deterioration (SVD) and mitral valve reoperation from any cause, and death was regarded as a competing risk. Competing risk analysis and propensity score-matching were used for comparisons.ResultsAmong the 388 patients enrolled, pericardial and porcine bioprostheses were implanted in 217 (55.9%) and 171 (44.1%), respectively. Propensity score-matching yielded 122 pairs of patients that were well-balanced for all baseline covariates. No significant differences were observed between the groups in unadjusted (p=0.09) and adjusted overall survival (hazard ratio [HR], 1.13; 95% confidence interval [CI], 0.72–1.76; p=0.60). Competing risk analysis revealed no significant differences in the risks of mitral reoperation (HR, 1.07; 95% CI, 0.50–2.27; p=0.86) and development of SVD (HR, 1.57; 95% CI, 0.56–4.36; p=0.39) between the groups. Matched population analysis confirmed similar results regarding reoperation (HR, 0.99; 95% CI, 0.40–3.22; p=0.98) and SVD (HR, 1.39; 95% CI, 0.41–4.73; p=0.60).ConclusionNo significant differences in survival or valve durability were observed between bovine pericardial and porcine bioprosthetic MVR. These findings require further validation through studies with larger sample sizes.

Hemodynamics in Adults With the Shone Complex

Patients with Shone complex (SC) have multiple left-sided obstructive lesions and thus are at risk for left ventricular (LV) remodeling, LV diastolic dysfunction and pulmonary hypertension. Yet, to date, there has been no description of hemodynamics in adults with SC. Retrospective chart review of 25 patients with SC who underwent cardiac catheterization at Mayo Clinic, MN between 2002 and 2019 was performed. SC was defined as multiple left-sided obstructive lesions in the presence of an anatomically abnormal mitral valve. Median age was 32 years (22.5, 42) and 15 patients (60%) were female. The majority of patients (84%) had history of coarctation of the aorta, 10 (40%) had subaortic stenosis, 11 (44%) had prior aortic valve replacement, and 10 (40%) had prior mitral valve replacement. Structural disease at the time of catheterization which warranted intervention within the next year was present in 13 patients (52%). The mean LV end-diastolic pressure was 21.3 ± 9.0 mm Hg (>15 mm Hg in 71%), pulmonary artery peak systolic pressure was 55.4 ± 13.4 mm Hg, and the pulmonary artery mean pressure was 37.0 ± 9.4 mm Hg (>20 mm Hg in 96%). During a mean follow-up of 8.3 ± 4.4 years, there were 7 deaths (28%) and 3 additional patients (12%) underwent cardiac transplantation. In conclusion, adults with SC who underwent catheterization showed significant left-sided heart and pulmonary vascular remodeling. Elevated LV end-diastolic pressure and pulmonary artery pressures were highly prevalent. There were high mortality and cardiac transplant rates in our cohort.

P295 Impact of Pre-existing Mitral Regurgitation on the Mid-Term Left Ventricular Mass Regression following Transcatheter Aortic Valve Implantation for Aortic Valve Stenosis

Abstract Background Transcatheter aortic valve implantation (TAVI) results in an immediate and greater aortic pressure gradient improvement in patients with severe aortic valve stenosis (AS), and induces early left ventricular (LV) mass regression, which may be related to favorable effects on the mid to long term outcomes. However, the extent of LV mass regression after unloading of chronic pressure overload is varying, and its determinants are still unknown. Thus, the study aims to identify echocardiographic determinants of LV mass regression following TAVI. Methods We retrospectively screened all TAVI procedures in symptomatic AS from 2017 to 2019, and selected 74 successful TAVI cases that had serial echocardiographic studies both at the baseline and at the mid-term follow-up (4 to 6 months after the procedure). Through the digitalized medical records, clinical and echocardiographic data as well as angiographic grading (0-3) of post-procedure paravalvular leakage (PVL) were obtained. LV mass was calculated by using Cube formula. Thus, the extent of LV mass regression was defined as the differences of left ventricular mas index (LVMI) between at the baseline and at the follow-up (ΔLVMI). Quantification of the baseline mitral valve regurgitant volume was performed by stroke volume method with pulmonic site measurement on the assumption of no pre-existing intra/extra cardiac shunt. Cases with prior mitral valve replacement were excluded. Results At the post-procedure angiogram, only 3 cases had significant PVL (grade 2≤). At the mid-term follow–up, average LVMI decreased significantly from the baseline (165 ± 38 g/m2vs 140 ± 37 mg/ m2, P < 0.0001) and 57 cases (70%) experienced the reduction of LVMI, although average relative wall thickness (2 × posterior wall thickness/left ventricular diastolic dimension) did not change (0.565 ± 0.135 vs 0.586 ± 0.168, P = 0.314). Among the baseline clinical and echocardiographic variables, the baseline peak A wave velocity, E/A ratio, mitral valve regurgitant volume and LVMI revealed simple correlation with ΔLVMI (γ=-0.298, p = 0.0188;γ=0.251, P = 0.0417;γ=0.354, p = 0.0041;γ=0.375, p < 0.0010; respectively), whereas no correlation was observed in angiographic PVL grade. Stepwise multiple regression analysis demonstrated baseline mitral valve regurgitant volume and LVMI as the determinants of ΔLVMI (β=0.344, p = 0.032; β=0.335 P < 0.0001; respectively). Conclusions Pre-existing mitral regurgitation has an impact on the mid–term left ventricular mass regression following TAVI. In severe AS, mitral regurgitation might be functioning as an afterload adjuster, and thus, produces protective effects on LV structure.

僧帽弁置換術, 冠動脈バイパス術後, 感染性心内膜炎による僧帽弁位人工弁周囲逆流を生じた症例に対し, 再弁置換術を右開胸で施行した1例

僧帽弁置換術, 冠動脈バイパス術後, 感染性心内膜炎による僧帽弁位人工弁周囲逆流を生じた症例に対し, 再弁置換術を右開胸で施行した1例

Trans-catheter Aortic Valve Implantation in Patients with Previous Mitral Valve Replacement: A Case Series

Introduction: Transcatheter aortic valve implantation is a routine clinical method for patients with severe aortic stenosis at high surgical risk, such as previous cardiac surgery. The presence of mechanical mitral prosthesis might complicate trans-catheter aortic valve implantation because of possible interference between both prostheses. Some clinical reports have already demonstrated the feasibility of trans-catheter aortic valve implantation in such patients. Methods and results: We report 4 patients with severe symptomatic aortic stenosis who had prior mitral valve replacement that successfully underwent trans-catheter aortic valve implantation with Sapien XT (Edwards Lifesiences, Irvine, USA) and CoreValve (Medtronic, Irvine, USA) aortic prosthesis. Multi-slice computed tomographic angiography was used for the assessment of the distance between both aortic and mitral prosthesis annuli. Trans-esophageal echocardiography was introduced for precise positioning of trans-catheter aortic valve. There were no special technical tips besides precise positioning and slow opening of the valve prosthesis. In case of CoreValve the goal was the positioning close to “zero point” and in case of Edwards Sapien valve higher as a “halfon- half” position according to natural aortic valve. We observed no deformation or dysfunction of aortic and mitral prosthesis in any of the patients. Balloon aortic valvuloplasty prior to implantation is not mandatory; however it helps to observe the mutual effect of the new aortic valve and pre-existent mitral prosthesis. Conclusions: We conclude that trans-catheter aortic valve implantation can be safely and successfully performed in patients with mechanical mitral prosthesis. It is important to carefully evaluate the anatomical conditions with trans-esophageal echocardiography and computed tomographic angiography. Skillfulness and experience of the operators should not be neglected.

Prognostic Importance of Diastolic Dysfunction in Relation to Post Procedural Aortic Insufficiency in Patients Undergoing Transcatheter Aortic Valve Replacement.

We sought to examine whether baseline diastolic dysfunction (DD) is associated with increased mortality in patients who develop aortic insufficiency (AI) after transcatheter aortic valve replacement (TAVR). Significant post-TAVR AI is associated with increased mortality, likely secondary to adverse hemodynamics secondary to volume overload and decreased LV compliance from chronic pressure overload. However, the effect of baseline DD on outcomes of patients with post-TAVR AI has not been studied. A total of 195 patients undergoing TAVR were included in the study. Patients with moderate-to-severe mitral stenosis, prior mitral valve replacement or atrial fibrillation were excluded. DD was classified at baseline by a 2-step approach as recommended by the American Society of Echocardiography while AI was evaluated 30 days post-TAVR. Follow up data up to 2 years post-TAVR was used in survival analysis. Patients with severe baseline DD who developed ≥mild post-TAVR AI had increased mortality compared to all other patients (HR = 3.89, CI: 1.76-8.6, P = 0.001), which remained significant after adjusting for post-TAVR AI, pre-TAVR AI, baseline mitral regurgitation, ejection fraction, pulmonary artery pressure, creatinine clearance and history of stroke. Even mild post-TAVR AI may have a negative impact on outcomes of patients with underlying severe DD. © 2016 Wiley Periodicals, Inc.

Inadvertent puncture of the aortic noncoronary cusp during postoperative left atrial tachycardia ablation

Transseptal catheterization has become part of the interventional electrophysiologist׳s technical armamentarium since the development of left atrial catheter ablation and percutaneous technologies for treating mitral and aortic valve disease. Although frequently performed, the procedure׳s most feared complication is aortic root penetration. Focal atrial tachycardia has been described as the most common late sequela of surgical valve replacements. We present a complicated case involving the inadvertent delivery of an 8 French sheath across the noncoronary cusp during radiofrequency catheter ablation for left atrial tachycardia originating from the mitral annulus in a patient with prior mitral valve replacement.

Annulus upsizing for mitral valve re-replacement in children

Mitral valve replacement remains the last resort for treatment of congenital mitral valve disease. Enlarging the mitral annulus at the time of mitral valve replacement may allow implantation of a larger prosthesis in children. All mitral valve replacement procedures from 1990 to 2012 were included, and mitral annulus enlargement techniques were analyzed. A control group of patients undergoing replacement of a previously implanted mechanical mitral valve prosthesis was compared with the cohort of patients who underwent annular enlarging procedures. Primary end points were increases in annulus size and Z score, and freedom from paced rhythm. Among 205 mitral valve replacement procedures, 16 (8%) included techniques to upsize the mitral annulus in 15 patients, all but 1 of whom had undergone prior mitral valve replacement. These patients were compared with a control cohort of 53 patients undergoing mitral valve re-replacement without annulus enlargement. The annulus was upsized by 18% ± 11% (compared with 16% ± 20% in controls, P = .5) using open balloon dilation in 4 patients, radial annular incisions in 5 patients, and patch augmentation of the aorto-mitral continuity in 7 patients. The mean valvar diameter Z score increased from -0.2 ± 1.3 to +1.1 ± 1.4 (P < .001), compared with an increase from -0.3 ± 1.2 to 0.9 ± 1.1 in controls (P < .001). During a mean follow-up of 6.5 ± 6.4 years, 4 of 12 patients required permanent pacing in the upsizing group (predominantly with patch augmentation), versus 5 of 53 patients in the control group. In children undergoing mitral valve replacement, various techniques can be used to upsize the mitral annulus and allow implantation of a larger prosthesis. There is a nontrivial risk of heart block with annulus upsizing, which deserves further study.

Quantitative evaluation of change in coexistent mitral regurgitation after aortic valve replacement

Management of intermediate degrees of mitral regurgitation during aortic valve replacement for aortic stenosis remains controversial. We sought to evaluate the degree of reduction of mitral regurgitation in patients undergoing aortic valve replacement, as well as a mathematical relationship between aortic valve gradient reduction and the degree of mitral regurgitation decrement. We retrospectively analyzed demographic, intraoperative, and echocardiographic data on 802 patients who underwent aortic valve replacement or aortic root replacement between January 2010 and March 2011. A total of 578 patients underwent aortic valve replacement or aortic root replacement without intervention on the mitral valve. We excluded 88 patients with severe aortic insufficiency, 3 patients who underwent ventricular assist device placement, 4 patients who underwent prior mitral valve replacement, and 21 patients with incomplete data, yielding 462 patients for analysis. For each patient, the degree of pre- and postoperative mitral regurgitation was graded on a standard 0 to 4+ scale. Of the 462 patients, 289 patients had at least mild mitral regurgitation. On average, mitral regurgitation decreased 0.24 degrees per patient for this cohort of 289 patients. Of the 56 patients with at least moderate mitral regurgitation, mitral regurgitation decreased 0.54 degrees per patient. Of 62 patients who underwent isolated aortic valve replacements, who had at least mild mitral regurgitation, and who had no evidence of structural mitral valve disease, mitral regurgitation decreased 0.24 degrees per patient. Linear regression analysis revealed no relationship between reduction in mitral regurgitation and gradient reduction across the aortic valve. Reduction in mitral regurgitation after relief of aortic outflow tract obstruction is modest at best. Further, the magnitude of gradient change across the aortic valve has little influence on the degree of reduction in mitral regurgitation. These observations argue at minimum for performing a prospective evaluation of the clinical benefits of addressing moderate mitral regurgitation at the time of aortic valve intervention and may support a more aggressive approach to concomitant mitral surgery.

Successful Tavi in Patients with Previous Mitral Valve Replacement

Background: Transcatheter aortic valve implantation (TAVI) is a new method for patients with severe aortic stenosis at high surgical risk, such as previous cardiac surgery. The presence of mechanical mitral prosthesis might complicate TAVI because of possible interference between both prostheses. Some reports have already demonstrated the feasibility of TAVI in such patients. Case Reports: We report 2 patients with severe symptomatic aortic stenosis who had prior mitral valve replacement that successfully underwent TAVI with Edwards Sapien and CoreValve aortic prosthesis, re- spectively. Computed tomographic angiography (CTA) was useful for the assessment of the distance between both aor- tic and mitral prosthesis annuli. Transesophageal echocardiography was crucial for precise positioning of TAV. There were no special technical tips besides precise positioning of the valve prosthesis. In case of Core Valve the goal was the positioning at “zero point” and in case of Edwards Sapien valve a “half-on-half” position according to natural aortic valve. We observed no deformation or dysfunction of aortic and mitral prosthesis in any of the patients. Balloon valvu- loplasty prior to implantation helps to observe the mutual effect of the new aortic valve and pre-existent mitral prosthe- sis. Conclusions: We conclude that TAVI can be safely and successfully performed in patients with mechanical mitral prosthesis carefully considering the altered anatomical conditions. Skillfulness and TAVI experience of the operators should not be neglected.

Feasibility of catheter ablation of mitral annular flutter in patients with prior mitral valve surgery

Mitral annular flutter (MAF) may occur after ablation of atrial fibrillation in patients with prior mitral valve (MV) replacement or repair. Percutaneous catheter ablation may be challenging owing to the presence of surgical scar and a prosthetic MV. We examined the feasibility of and outcome after mitral isthmus ablation in patients with prior MV surgery. Twenty-one consecutive patients (18 males, age 61 ± 10 years) with a history of MV surgery (nine replacement, 12 repair with annuloplasty ring) underwent catheter ablation of clinical (n = 17) or easily inducible (n = 4) MAF (group 1). Patients were matched for age, gender, and ejection fraction, with 21 patients undergoing MAF ablation without prior MV surgery (group 2). Irrigated ablation was delivered endocardially in a linear fashion from the MV to the left inferior and/or to the right superior pulmonary vein and, when required, epicardially inside the coronary sinus. Isolation of all pulmonary veins was also performed. There was no difference in termination of tachycardia during ablation (group 1 vs. group 2; 86% vs. 71%; P = .454), achieving mitral isthmus block (71% vs. 71%; P = 1.000), or need for epicardial ablation (43% vs. 62%; P = .354) between groups. No complications occurred in either group. After a mean follow-up of 7 ± 4 months, 15 (71%) patients in group 1 and 14 (67%) in group 2 had no recurrence of atrial arrhythmias. Percutaneous mitral isthmus ablation is feasible and safe in patients with prior MV replacement or repair and has comparable outcomes to patients without prior MV surgery.

Atrial Tachyarrhythmias Concomitant with Perimitral Atrial Flutter during Catheter Ablation

Background: We report 3 cases demonstrating transition from perimitral atrial flutter to a different atrial tachycardia/flutter (AT/AFL) during linear ablation between the left pulmonary vein (PV) and the mitral annulus (mitral isthmus ablation). Methods: N/A. Results: A 67-year-old man with prior pulmonary vein isolation (PVI) underwent RFCA for recurrent AFL. Electrophysiological study (EPS) initially revealed clockwise perimitral AFL. During mitral isthmus ablation, the AFL changed into a focal AT from left atrial (LA) inferior wall with change in cycle length (CL) from 230 ms to 310 ms, which was successfully ablated at the earliest atrial activation site. A 70-year-old woman with prior mitral valve replacement and atrial fibrillation (AF) underwent RFCA for persistent AFL. EPS revealed clockwise perimitral AFL (CL=270 ms). During mitral isthmus ablation, the AFL changed into common AFL without change in CL, thus the two AFLs formed a dual-loop reentry circuit over both atria. A 65-year-old woman with prior PVI underwent RFCA for recurrent AFL. EPS revealed counterclockwise perimitral AFL. During mitral isthmus ablation, the AFL changed into a LA roof dependent AFL with change in CL from 205 ms to 250 ms, which was successfully terminated by LA roof linear ablation. Conclusion: Perimitral AFL can occur simultaneously with another AT/AFL, which becomes apparent with termination of perimitral AFL.

Catheter Ablation for Peri-Mitral Atrial Flutter Post Mitral Valve Replacement

Peri-mitral atrial flutter (PMFL) may occur in patients with prior mitral valve replacement (MVR). Catheter ablation (CA) may be challenging owing to prosthetic valve and the surrounding scar. A 61 year-old man underwent MVR and LA maze procedure in 2005. He was admitted to our hospital in 2011 because of atrial flutter (AFL). CA for AFL was performed. In EPS findings, PV-LA connections were isolated by prior maze procedure. CARTO mapping during tachycardia (CL=290 msec), and revealed PMFL. Radiofrequency application with an irrigated-tip catheter using Agilis sheath at the mitral isthmus successfully eliminated this tachycardia. We confirmed the MI block line by the sequence of CS activation while pacing from the LAA, but the MI block line was incomplete. The activation map on the CARTO system during LAA pacing revealed early activation site with a fractionated potential near the MI (LAA pacing site to ABL distal pole interval was 80 ms). The bidirectional conduction block line was created in the MI by additional RF current application at this conduction gap. The interval from the LAA pacing site to CS distal pole prolonged from 130 msec to 230 msec. This case report highlights the rare case of successful CA for PMFL in a patient with prior MVR.

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

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