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Pan Y, Zhou Y, Liu Y, Peng Z, Liu L, Yang Y, Hua K, Yang X. Double-layer horizontal cross sutures for intra-atrial mitral valve implantation: An effective surgical method for severe mitral annular calcification. JTCVS Tech 2023; 22:28-38. [PMID: 38152208 PMCID: PMC10750836 DOI: 10.1016/j.xjtc.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 12/29/2023] Open
Abstract
Objective Severe mitral annular calcification (MAC) can make prosthetic implantation extremely difficult. Although intra-atrial mitral valve prosthesis implantation without annular decalcification offers a simpler approach, it poses a potential rupture risk due to high left ventricular pressure. We developed a double-layer (DL) horizontal cross-suture technique, which ensures close proximity of the valve prosthesis to the calcified annulus and segregates the left atrial wall from the left ventricle. The aim of this study was to compare the outcomes of DL suture with conventional single-layer (SL) suture in patients with severe MAC. Methods This retrospective cohort study consecutively enrolled patients with severe MAC undergoing mitral valve replacement at Beijing Anzhen Hospital from May 2018 to December 2022. A detailed description of the DL suture method is described. Follow-up medical evaluations, including transthoracic echocardiography measurements, were obtained through outpatient chart reviews. Results The study included 10 patients in the DL suture group and 20 in the SL suture group. All patients in the DL group and all but 3 in the SL group achieved technical success. Compared with the SL group, the DL suture technique was associated with lower rates of perivalvular leakage, stroke, new-onset atrial fibrillation, reoperation, and 30-day mortality. Follow-up was complete, with 1 late mortality in the DL group due to stroke and 4 cardiovascular deaths in the SL group. Conclusions The DL horizontal cross-suture technique offers a more effective and safer approach for intra-atrial mitral valve implantation in severe MAC cases than the conventional SL suture method.
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Affiliation(s)
- Yilin Pan
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuan Zhou
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yuhua Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhan Peng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Linqi Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yunxiao Yang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kun Hua
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiubin Yang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Neuartige Operationstechnik zur schweren Verkalkung des Mitralanulus. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022. [DOI: 10.1007/s00398-022-00514-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Surgical implantation of balloon-expandable heart valves for the treatment of mitral annular calcification. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01245-9. [PMID: 34635317 DOI: 10.1016/j.jtcvs.2021.08.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The treatment of mitral valve disease in the presence of mitral annular calcification (MAC) is associated with an increased risk of cardiovascular and all-cause mortality. Various surgical and transcatheter techniques for the treatment of mitral disease with severe MAC have been described. However, these procedures are associated with high risk of operative morbidity and mortality. We describe our experience with open surgical implantation of a balloon-expandable valve (BEV) in patients with severe MAC as an alternative approach. METHODS BEV implantation was performed with direct vision through the left atrium via a median sternotomy or minimally invasive approach. The midportion of the anterior leaflet is excised, and a ventricular septal myectomy performed if there is high risk for left ventricular outflow tract obstruction. The primary outcome was technical success according to the Mitral Valve Academic Research Consortium criteria; secondary outcomes were 30-day and 1-year mortality. RESULTS From October 2015 through October 2020, 51 patients at 2 institutions underwent BEV-in-MAC (mean age, 73.9 ± 8.8 years; 60.8% [31/51] were female; mean Society of Thoracic Surgeons predicted risk of mortality: 6.8% ± 4.8%). Technical success was 94.1% (48/51). Thirty-day and 1-year mortality were 13.7% (7/51) and 33.3% (15/45), and for stroke 3.9% (2/51) and 4.4% (2/45), respectively. CONCLUSIONS Surgical implantation of a BEV in the mitral position offers a treatment option for patients with mitral valve disease complicated by severe MAC who are at increased risk for conventional surgical approaches and at risk for left ventricular outflow tract obstruction with transcatheter approaches.
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Van Hemelrijck M, Taramasso M, Gülmez G, Maisano F, Mestres CA. Mitral annular calcification: challenges and future perspectives. Indian J Thorac Cardiovasc Surg 2020; 36:397-403. [PMID: 33061148 PMCID: PMC7525373 DOI: 10.1007/s12055-019-00910-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/13/2019] [Accepted: 09/29/2019] [Indexed: 10/25/2022] Open
Abstract
Mitral annular calcification (MAC) is a chronic degenerative process that implies calcification on the mitral support structure. It usually appears as a bystander to other cardiac pathologies hindering surgical treatment and increasing morbidity and mortality. When addressing the mitral valve, many surgical strategies have been suggested in the past with no clear consensus on what to choose. Moreover, and as transcatheter therapies have gained popularity over the last few decades, transcatheter mitral valve implantation has appeared as another alternative to conventional surgery. In this review, we aim at describing an overview of MAC, highlighting current challenges and treatment options as well as new potential alternatives.
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Affiliation(s)
- Mathias Van Hemelrijck
- Department of Cardiac Surgery, University Hospital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Maurizio Taramasso
- Department of Cardiac Surgery, University Hospital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Gökhan Gülmez
- Department of Cardiac Surgery, University Hospital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Francesco Maisano
- Department of Cardiac Surgery, University Hospital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Carlos-A. Mestres
- Department of Cardiac Surgery, University Hospital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland
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Intra-atrial Neomitral Ring Creation in the Presence of Severe Mitral Annulus Calcification. Ann Thorac Surg 2020; 110:e343-e345. [PMID: 32389565 DOI: 10.1016/j.athoracsur.2020.03.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/16/2020] [Accepted: 03/25/2020] [Indexed: 11/22/2022]
Abstract
Severe mitral annulus calcifications significantly hinder surgical repair and replacement of the dysfunctional mitral valve. Herein, we present a novel surgical technique where we created an intra-atrial neomitral ring using a vascular Dacron graft in which a prosthetic valve was implanted. This approach is a simple alternative technique that can be used when anatomic prosthetic valve implantation is not feasible. Major assets of this approach are evasion of extensive debridement, implantation of an adequately sized prosthesis, and prosthetic material availability.
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Russell HM, Guerrero ME, Salinger MH, Manzuk MA, Pursnani AK, Wang D, Nemeh H, Sakhuja R, Melnitchouk S, Pershad A, Fang HK, Said SM, Kauten J, Tang GHL, Aldea G, Feldman TE, Bapat VN, George IM. Open Atrial Transcatheter Mitral Valve Replacement in Patients With Mitral Annular Calcification. J Am Coll Cardiol 2019; 72:1437-1448. [PMID: 30236304 DOI: 10.1016/j.jacc.2018.07.033] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mitral valve replacement in the setting of severe mitral annular calcification remains a surgical challenge. Transcatheter mitral valve replacement (TMVR) using an aortic balloon-expandable transcatheter heart valve is emerging as a potential treatment option for high surgical risk patients. Transseptal, transapical, or transatrial access is not always feasible, so an understanding of alternative implantation techniques is important. OBJECTIVES The authors sought to present a step-by-step description of a contemporary transatrial TMVR technique using balloon-expandable aortic transcatheter heart valves. This procedure has evolved over time to address valve migration, left ventricular outflow tract obstruction, and paravalvular leak. The authors present a refined technique that has been associated with the most reproducible outcomes. METHODS A step-by-step description of the TMVR technique and outcomes of 8 patients treated using this technique are described. Baseline patient clinical and echocardiographic characteristics and 30-day post-TMVR outcomes are presented. RESULTS Eight patients underwent transatrial TMVR at a single institution. Five had previous cardiac surgery. Mean STS score was 8%. Technical success by MVARC (Mitral Valve Academic Research Consortium) criteria was 100%. There was zero in-hospital and 30-day mortality. Procedural success by MVARC criteria at 30 days was 100%. Paravalvular leak immediately post-implant was none or trace in 6 and mild in 1. CONCLUSIONS The technique described is reproducible and was associated with favorable outcomes in this early experience. It represents a useful technique for the treatment of mitral valve disease in the setting of severe annular calcification. A structured and defined implantation technique is critical to investigators as this field evolves.
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Affiliation(s)
- Hyde M Russell
- Division of Cardiovascular Surgery, NorthShore University HealthSystem, Evanston, Illinois.
| | - Mayra E Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic Hospital, Rochester, Minnesota
| | - Michael H Salinger
- Division of Cardiology and Cardiovascular Surgery, Froedtert/Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Melissa A Manzuk
- Division of Cardiovascular Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Amit K Pursnani
- Division of Cardiology, NorthShore University HealthSystem, Evanston, Illinois
| | - Dee Wang
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan
| | - Hassan Nemeh
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan
| | - Rahul Sakhuja
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashish Pershad
- Banner-University Medicine Heart Institute, Phoenix, Arizona
| | - H Kenith Fang
- Banner-University Medicine Heart Institute, Phoenix, Arizona
| | - Sameh M Said
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - James Kauten
- Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York
| | - Gabriel Aldea
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington
| | - Ted E Feldman
- Division of Cardiology, NorthShore University HealthSystem, Evanston, Illinois
| | - Vinnie N Bapat
- Division of Vascular, Thoracic and Cardiac Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Isaac M George
- Division of Vascular, Thoracic and Cardiac Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
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Open atrial transcatheter mitral valve replacement in patients with mitral annular calcification. J Thorac Cardiovasc Surg 2019; 157:907-916. [DOI: 10.1016/j.jtcvs.2018.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/02/2018] [Indexed: 11/15/2022]
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Onorati F, Gatti G, Perrotti A, Mariscalco G, Reichart D, Milano A, Della Ratta E, Rubino A, Santarpino G, Salsano A, Biancari F, Detter C, Chocron S, Beghi C, De Feo M, Mignosa C, Fischlein T, Pappalardo A, D'Errigo P, Santini F, Faggian G. Impact of failed mitral valve repair on hospital outcome of redo mitral valve procedures. Eur J Cardiothorac Surg 2018; 51:906-912. [PMID: 28204140 DOI: 10.1093/ejcts/ezw436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 11/21/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The prognostic impact of failed mitral valve repair (FMR) on in-hospital outcome after redo mitral valve surgery has not been thoroughly investigated. METHODS Hospital outcomes after redo mitral valve surgery because of an FMR in patients from nine European centres were reported. Logistic regressions identified predictors of mortality in combined or isolated redo mitral valve operations. Hospital outcome was compared between propensity-matched cohorts with FMR and native mitral valves in the context of redo surgery and FMR versus failed prostheses. RESULTS A total of 246 patients with FMR yielded a 6.5% mortality rate at redo surgery. FMR per se did not impact mortality at multivariable analysis ( P = 0.64). A preoperative Global Initiative for Chronic Obstructive Lung Disease (GOLD) score ≥2 chronic obstructive lung disease (COPD) (OR 15.2, P < 0.01), left ventricular ejection fraction <30% (odds ratio (OR) 21.5, P = 0.005), major injury to cardiovascular structures at re-entry (OR 27.2, P < 0.01) or injury to patent left internal mammary artery-coronary artery bypass graft (OR 7.6, P = 0.03) predicted mortality in the whole FMR population. GOLD ≥ 2 COPD (OR 12.3, P = 0.049), age at surgery (OR 1.15 for each incremental year, P = 0.049) and cardiopulmonary bypass duration (OR 1.02, P = 0.022) predicted mortality in isolated redo mitral valve surgery for FMR. The fourth (> 68 years = 13.8% mortality) and the fifth quintiles of age (≥73.4 years = 14.8%) reported the highest mortality (OR 3.8 and 4.2 respectively, P = 0.002) in this subgroup. Propensity-matched cohorts of FMR and native mitral valves in the context of redo surgery showed no differences in terms of mortality ( P = 0.69) and major morbidity (acute myocardial infarction P = 0.31, stroke P = 0.65, acute kidney injury P = 1.0), whereas more perioperative dialysis ( P = 0.04) and transfusions ( P = 0.02) were noted in propensity-matched failed prostheses compared to FMR. CONCLUSIONS A failed mitral repair does not impact hospital outcome of redo surgery. Given the role of severe left ventricular dysfunction and advanced age on hospital mortality rates, an early indication for redo surgery may improve outcome.
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Affiliation(s)
| | - Giuseppe Gatti
- Division Cardiac Surgery, A.O.U. Riuniti, Trieste, Italy
| | - Andrea Perrotti
- Department Cardiac Surgery, University Hospital of Becancon, France
| | | | - Daniel Reichart
- Division Cardiac Surgery, Univesitat Klinikum Eppendorf, Hamburg, Germany
| | - Aldo Milano
- Division Cardiac Surgery, University of Verona, Verona, Italy
| | - Ester Della Ratta
- Department Cardiothoracic and Respiratory Sciences, Second University of Naples, Naples, Italy
| | - Antonio Rubino
- Division Cardiac Surgery, University of Catania, Catania, Italy
| | - Giuseppe Santarpino
- Cardiovascular Center, Klinikum Nürnberg - Paracelsus Medical University, Nuremberg, Germany
| | - Antonio Salsano
- Department Cardiac Surgery, University of Genoa, Genoa, Italy
| | - Fausto Biancari
- Department Cardiovascular Surgery, Oulu University, Oulu, Finland
| | - Christian Detter
- Division Cardiac Surgery, Univesitat Klinikum Eppendorf, Hamburg, Germany
| | - Sidney Chocron
- Department Cardiac Surgery, University Hospital of Becancon, France
| | - Cesare Beghi
- Cardiac Surgery Unit, University of Insubria, Varese, Italy
| | - Marisa De Feo
- Department Cardiothoracic and Respiratory Sciences, Second University of Naples, Naples, Italy
| | - Carmelo Mignosa
- Division Cardiac Surgery, University of Catania, Catania, Italy
| | - Theodor Fischlein
- Cardiovascular Center, Klinikum Nürnberg - Paracelsus Medical University, Nuremberg, Germany
| | | | - Paola D'Errigo
- National Centre for Epidemiology, Surveillance and Health Promotion - Istituto Superiore di Sanità, Rome, Italy
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Hassan M, Windsor J, Ricci M. En bloc aortic and mitral valve replacement and left ventricular outflow tract enlargement using a combined transaortic and trans-septal atrial approach. Interact Cardiovasc Thorac Surg 2015; 21:792-5. [PMID: 26409564 DOI: 10.1093/icvts/ivv267] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/11/2015] [Indexed: 11/13/2022] Open
Abstract
Aortic and mitral valve replacement with division and reconstruction of the inter-valvular fibrous body has been described in clinical situations involving infective endocarditis, extensive annular calcifications and diminutive valve annuli. Herein, we describe a combined transaortic and trans-septal approach with division of the inter-valvular fibrosa for combined aortic and mitral valve replacement. The reconstruction of the inter-valvular fibrous body, atrial walls and aortic root was carried out using a 'three-patch' technique with bovine pericardium.
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Affiliation(s)
- Mohammed Hassan
- Division of Cardiothoracic Surgery, Department of Surgery, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Jimmy Windsor
- Department of Anesthesiology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Marco Ricci
- Division of Cardiothoracic Surgery, Department of Surgery, University of New Mexico Health Science Center, Albuquerque, NM, USA
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