Mitral valve replacement with a collar-reinforced prosthetic valve for disrupted mitral annulus

Mitral valve replacement using a collar-reinforced mitral prosthesis for severe mitral annular calcification, which secures implantation in both the supra-annular and intra-atrial positions: a case report

BACKGROUND

Appropriate management of mitral annular calcification associated with mitral valve surgery must be determined on a case-by-case basis. However, an established procedure remains uncertain.

CASE PRESENTATION

This report describes a surgical case of severe mitral and aortic valve stenosis associated with severe mitral annular calcification in a 71-year-old woman who underwent mitral valve replacement with a collar-reinforced mitral prosthesis. The patient underwent surgical repair after the treatment for heart failure. As the present patient was deemed to be at high risk for conventional mitral valve replacement, we applied a composite prosthetic valve that was enlarged circumferentially on the ventricular side of the prosthesis with a bovine pericardial patch. First, the solid calcium bar was left untouched and only the friable calcified mass that was easily scattered was removed. Subsequently, the prosthesis was secured by two mattress sutures placed in the intra-atrial position at the region of the extended calcified myocardium. Additionally, ten mattress sutures were placed in the supra-annular position at the other regions capable of passing stitches from the ventricular side to the atrial side. Finally, a 1.5 cm wide trimmed bovine pericardial collar was sutured circumferentially from the annulus to the atrial wall using running 4-0 polypropylene for reinforcement. Although temporary hemodialysis was performed for acute renal failure, the patient remained asymptomatic.

CONCLUSIONS

The present case suggests that mitral valve replacement using a collar-reinforced mitral prosthesis may be an effective technique for severe mitral annular calcification. To avoid catastrophic complications associated with treatment for severely calcified annulus, it is crucial to make a prudent preoperative decision regarding the surgical strategy under circumstances where conventional mitral valve replacement is impossible.

A case of supra-annular mitral valve replacement using chimney technique for severe mitral stenosis with extensive mitral annular calcification

When patients with extensive mitral annular calcification undergo mitral valve replacement, excessive debridement of calcification may result in fatal complications and may protract operation time. We report a case of supra-annular MVR using "the chimney technique" on a high-risk patient for severe mitral stenosis with extensive mitral annular calcification. This technique is usually used in small infants whose mitral annulus is smaller than the smallest available prosthetic valve. We apply this technique to minimize the debridement of calcification and shorten the operation time. The operation was successfully completed, and the postoperative course has been uneventful. This technique was safely and easily performed, and eliminated the need for aggressive debridement of the calcification. We believe this technique may be a good choice for high-risk patients with mitral annular calcification.

Juxta-annular right atrial anchoring of prosthetic mitral valves in endocarditis with anterior annulus destruction†

Destruction of the mitral annulus is associated with poor outcomes. We present the treatment of endocarditis using a technique that enables secure anchoring of prosthetic valves where the anterior part of the mitral annulus is severely disrupted. It was used in 5 patients. Follow-up at 10 ± 4 months showed the valves intact without recurrence of endocarditis. Mortality was limited to 1 patient who died of non-cardiac causes. We conclude that partial right atrial anchoring is a useful bail-out and enables favourable outcomes in patients with extensive loss of the (peri)annular tissue due to endocarditis.

Modified intraatrial translocation for prosthetic mitral valve endocarditis

Despite prompt diagnosis and aggressive surgical treatment of prosthetic mitral valve endocarditis (PVE), morbidity and mortality remain high. Surgical strategies have mostly been limited to debridement and anatomic valve reinstallation. Alternative surgical techniques have been attempted sporadically against this mortal disease, either with protection by antibiotic sewing rings or by anatomic evacuation of infectious foci. These methods have not been performed concurrently, however, and their joint deployment might improve surgical outcome. We describe a surgical procedure of modified intraatrial translocation combined with sewing ring shielding, aimed at preventing the recurrence of severe methicillin-resistant staphylococci PVE in the mitral position.

Implantation of collar-reinforced sumit valve for patient with large calcified mass obstructing the mitral valve orifice

A 56-year-old female had a severely calcified mitral valve annulus and a huge subvalvular mass. To avoid critical damages of the coronary artery and left ventricle, the annular calcification and the part of the mass adherent to the left ventricle were not resected. Then we performed mitral valve replacement using SuMit valve and collared reinforcement technique with xenopericardium without any major complications. The SuMit valve is designed to be placed in a supraannular position, and is useful to prevent valves from getting stuck.

Mitral valve replacement in the presence of massive posterior annular calcification

Replacement of the mitral valve in the presence of extensive calcification of the posterior annulus is a technical challenge. The heavily calcified annulus often results in difficulties of seating the prosthesis and later periprosthetic leakage. A radical calcium debridement may leave a friable and thin annulus that contributes to the risks of prosthesis dehiscence and ventricular perforation. To avoid technical difficulties and associated catastrophic complications, we devised a new technique of mitral valve replacement that allows a surgeon to implant a prosthesis securely. This technique involves inserting a larger single tilting disc mechanical valve (Medtronic Hall disc) with intra-atrial anchorage over the posterior sector of the calcified annulus, orienting the working (major) orifice of the mechanical valve anteriorly, and thereby tilting the lesser occluder segment of the disc upward into the atrium and away from the calcification in diastole. By utilizing this method, we have successfully performed mitral valve replacement in two patients who exhibited massive calcification of the posterior mitral annulus. Postoperative transeosophageal echocardiography showed excellent hemodynamic performance of the implanted valves. We therefore recommend this simple, safe, and time-saving procedure as a feasible method to deal with this surgical dilemma.