CASE REPORT – ADULT CARDIAC

Interactive CardioVascular and Thoracic Surgery 19 (2014) 1080–1082 doi:10.1093/icvts/ivu306 Advance Access publication 9 September 2014

Mitral valve repair without mitral annuloplasty with extensive mitral annular calcification Akimasa Morisaki*, Yasuyuki Kato, Yosuke Takahashi and Toshihiko Shibata Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan * Corresponding author. Department of Cardiovascular Surgery, Osaka City General Hospital, 2-13-22 Miyakojima-Hondori, Miyakojima-ku, Osaka 534-0021, Japan. Tel: +81-6-69291221; fax: +81-6-69292041; e-mail: [email protected] (A. Morisaki). Received 23 May 2014; received in revised form 5 August 2014; accepted 13 August 2014

Abstract In mitral valve repair, removal of mitral annular calcification (MAC) is necessary to secure the artificial ring but may cause rupture of the left ventricle or injury to the circumflex coronary artery. We experienced 3 cases of mitral valve regurgitation with extensive MAC. Patient 1, an 83-year old woman, had P1-P2 prolapse due to tendon rupture. We performed mitral valve repair with triangular resection of P2 and patch reconstruction, artificial-chordal reconstruction to P2 and anterolateral commissural edge-to-edge suturing. Patient 2 was a 76-year old man with P3 prolapse due to tendon rupture. We performed A3-P3 edge-to-edge suturing and small annular plication of the posteromedial commissure. Patient 3, an 84-year old woman with a non-specific coaptation defect in the anterolateral commissure and tenting of the anterior mitral leaflet due to a secondary chorda, underwent cutting of the secondary chorda of the anterior mitral leaflet and A1-P1 edge-to-edge suturing. We performed tricuspid annuloplasty in Patient 1 and aortic valve replacement in Patients 2 and 3. Postoperative echocardiography showed good control of mitral valve regurgitation, which we were able to regulate by repairing the leaflets and chordae without decalcification of the mitral annulus or implantation of an artificial ring. Keywords: Mitral annular calcification • Mitral valve regurgitation • Mitral valve repair

INTRODUCTION Mitral annular calcification (MAC) can increase the difficulty of mitral valve procedures. Removal of extensive MAC is associated with risks of posterior atrioventricular groove rupture and circumflex coronary artery injury [1, 2], and a surgical mortality rate of up to 9% has been reported for patients undergoing extensive decalcification procedures [3]. MAC is often associated with older patients and those with renal failure [2]; thus, it may be preferable to perform a mitral valve procedure without addressing MAC to reduce morbidity and mortality. We herein describe cases of simple mitral valve leaflet repair and/or mitral subvalvular apparatus repair without implantation of an artificial ring.

CASE REPORT We operated on 3 patients with mitral valve regurgitation. All patients were over 75 years old, and computed tomography revealed extensive, near-circumferential MAC (see Supplementary material, Fig. S1). Patient characteristics are summarized in Table 1. Although Patients 2 and 3 had severe aortic stenosis that may have affected their congestive heart failure, mitral valve repair was required because the mitral valve exhibited degenerative disease with moderate mitral regurgitation associated with a high possibility of devastating postoperative heart failure. Patient 2 had a long history of haemodialysis, and Patient 3 required intra-aortic balloon pump support for haemodynamic instability

before surgery. The aetiology of mitral valve regurgitation in each case as assessed by echocardiography is given in Table 1. Supplementary material, Fig. S2A shows mitral valve prolapse as detected by transoesophageal echocardiography in Patient 1. The severity of mitral valve regurgitation was scored by the echocardiography findings [4]. The left ventricular function was decreased in Patient 3 with an ejection fraction of 45% on intra-aortic balloon pump support. Each operative schema is summarized in Fig. 1. We performed the operations in January 2011 and August 2012 in Patients 1 and 2/3, respectively. Commissural edge-to-edge sutures were performed in all cases. Patient 1 underwent minimal triangular resection of the calcified P2 leaflet followed by patch reconstruction with an autologous pericardial patch and artificial-chordal reconstruction to the P2 leaflet. We performed a small annular plication of the posterior commissure in Patient 2; in Patient 3, we cut a thickened secondary chorda of the anterior mitral leaflet. We also added mitral leaflet cleft suturing between P2 and P3 in Patients 2 and 3 because of small leakage from the cleft. No regurgitation was seen on saline testing in any patient. We then performed tricuspid annuloplasty in Patient 1 and aortic valve replacement in Patients 2 and 3. Patient 1 was extubated 20 h postoperatively and was discharged uneventfully on postoperative day 16. Patient 2 was extubated 12 h postoperatively and was discharged uneventfully on postoperative day 17. Patient 3 underwent removal of the intra-aortic balloon pump on postoperative day 2 and was extubated 90 h postoperatively. On postoperative day 24, Patient 3

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

A. Morisaki et al. / Interactive CardioVascular and Thoracic Surgery

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Table 1: Patient profiles Case

Age (years), sex

Diagnosis

Comorbidities

Aetiology of MR

Severity of mitral valve regurgitation

Mitral annular diameter by TTE (4 ch/2 ch, mm)

1

83, female

Severe MR, severe TR

28.1/27.7

76, male

Severe MR, severe AS

P1-P2 prolapse due to tendon rupture P3 prolapse due to tendon rupture

Grade III (11 points)

2

Grade III (12 points)

35.6/36.7

3

84, female

Moderate MR, severe AS

Atrial fibrillation, diabetes mellitus Haemodialysis, chronic rheumatoid arthritis Low EF, on IABP support

Grade II–III (9 points)

31.2/32.5

Loss of coaptation in anterolateral commissure Tenting of anterior mitral leaflet by secondary chorda tethering

AS: aortic stenosis; EF: ejection fraction; IABP: intra-aortic balloon pump; MR: mitral regurgitation; TR: tricuspid regurgitation; TTE: transthoracic echocardiography; 2 ch: two-chamber view; 4 ch: four-chamber view.

Figure 1: Operative schemas of mitral valve repair in extensive mitral annular calcification. (A) Patient 1: mitral valve repair with triangular resection of P2 followed by patch reconstruction, artificial-chordal reconstruction to P2 and anterolateral commissural edge-to-edge suturing. The mitral leaflet cleft was then sutured between P2 and P3. (B) Patient 2: A3-P3 edge-to-edge suturing and small annular plication of the posteromedial commissure (solid arrow). (C) Patient 3: cutting of secondary chorda of the anterior mitral leaflet (broken arrow) and A1-P1 edge-to-edge suturing. The mitral leaflet cleft was then sutured between P2 and P3.

29.6/31.2 mm) during the follow-up period (>2 years postoperatively), and all patients were in New York Heart Association class I or II.

DISCUSSION MAC is usually seen at a posterior site of the mitral annulus, and circumferential MAC is rare [2]. We performed 226 mitral valve

CASE REPORT

was transferred to another hospital for rehabilitation. In each patient, postoperative echocardiography showed minimal mitral regurgitation with a mean low-pressure gradient through the mitral valve (degree of mitral valve regurgitation/mean pressure gradient: Patient 1, trivial/3.0 mmHg; Patient 2, mild/3.8 mmHg; Patient 3, trivial/2.4 mmHg) (Supplementary material, Fig. 2B). The mitral regurgitation, mean pressure gradient and mitral annular diameter did not increase (four-chamber view/two-chamber view: Patient 1, 27.8/26.9 mm; Patient 2, 34.8/36.2 mm; Patient 3,

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repairs in 266 patients with mitral valve regurgitation from January 2010 to December 2013 in our institution. Only 5 patients with mitral valve regurgitation had extensive MAC. Three patients with mitral valve regurgitation had extensive MAC and underwent mitral valve repair without artificial ring implantation. Mitral valve repair mainly involves 3 procedures: repair of the leaflets, repair of the subvalvular apparatus (chordae) and annuloplasty with an artificial ring. Implantation of an artificial ring is usually performed to achieve good coaptation of the mitral leaflets and prevent future mitral annular dilatation. However, it is difficult to perform ring implantation without the removal of MAC because the needles cannot pass through the calcified annulus. Decalcification is associated with a risk of severe complications, such as left ventricular rupture. Therefore, we attempted to regulate the mitral valve regurgitation by simple repair of the leaflets and/or mitral subvalvular apparatus without artificial ring implantation. In patients with severe MAC, calcification often extends to the leaflet and subvalvular apparatus, causing most of these patients to require mitral valve replacement [2]. In our institution, of the 5 patients with mitral valve regurgitation and extensive MAC, 2 underwent mitral valve replacement because the MAC widely extended to the mitral leaflet and degenerative changes in the mitral leaflet were severe. However, only those patients with minimally calcified leaflets and subvalvular apparatus can undergo mitral valve repair. We were able to regulate the mitral valve regurgitation without artificial ring implantation using several repair techniques, including edge-to-edge repair, artificial chorda reconstruction, patch reconstruction and minimal resection and suturing. Without ring implantation, wide triangular- or quadrangularshaped resection leads to shortening of the mitral leaflets, which causes mitral regurgitation because of a reduced coaptation zone. Therefore, we considered patch reconstruction of the resected area of the leaflet to be suitable to maintain coaptation, and we were able to achieve good coaptation of the leaflets without mitral valve regurgitation. An artificial chorda for prolapsed leaflets is another technique that can maintain the mitral valve configuration. Commissural edge-to-edge suturing can lead to mitral valve stenosis, but may be permissible if it is performed on only one commissure. In all patients, the mean mitral valve pressure was

Mitral valve repair without mitral annuloplasty with extensive mitral annular calcification.

In mitral valve repair, removal of mitral annular calcification (MAC) is necessary to secure the artificial ring but may cause rupture of the left ven...
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