J Thorac Cardiovasc Surg 2004;127:609-610
© 2004 The American Association for Thoracic Surgery
Mitral valve surgery with extensive calcification of the annulus
Thomas J. Vander Salm, MD
To the Editor:
Feindel and coauthors1 report results in a challenging set of patients, those with mitral annular calcification (MAC) causing mitral regurgitation. Several alternative techniques to avoid excising the calcified bar all have disadvantages. Displacing the prosthetic sewing line into the left atrium (with or without a prosthetic cuff) subjects the left atrium to high ventricular pressure. Sewing to the mitral leaflets central to the calcified bar requires sewing to fragile tissue and downsizing the valve. Sewing to the calcified bar usually leads to dehiscence, and trying to pass the sutures around the bar jeopardizes the circumflex coronary artery.
An ultrasonic decalcification tool easily pulverizes and extracts the MAC.2,3 This device spares soft tissue, and hence the circumflex coronary artery is preserved. Because the left ventricle, left atrium, and mitral leaflet(s) are largely disconnected, reconstruction may require an annular patch as Feindel and coworkers1 describe for valve repair. For valve replacement, sutures passed from left atrium, to left ventricle, around the residual mitral leaflet, and through the prosthetic annulus suffice to reconstitute the annulus.2 Because the vital structures of the atrioventricular (AV) groove fall posteriorly, the visualization of the top of the left ventricle where it abuts the annulus allows the placement of sutures deep into the muscle without injuring the AV groove vessels.
I have used this technique in 38 patients, 19 of whose results were previously reported.3 The mean age was 73 years (range 56-84 years), and the mean circumferential calcification requiring debridement was 157° (range 45°-330°). Six patients had mitral repairs; 32 had replacements (17 St Jude Medical [St Jude Medical, Inc, St Paul, Minn], 15 porcine). At the time of operation, 2 patients were noted to have a posterior AV groove hematoma: 1 resolved without treatment, and 1 patient died 1 month postoperatively of multiorgan failure but the hematoma could not be shown to be a contributing factor. Four other patients died. None of the deaths were related to the annular decalcification. No patient developed a paravalvular leak. No patient suffered injury to the circumflex coronary artery or the coronary sinus.
This technique may be underappreciated and underused. I have been frustrated by attempts to excise the calcified bar as described by Carpentier and colleagues.4 It has seemed to be sufficiently imbedded in the annulus and adjacent structures that I feared damaging the circumflex coronary artery or great coronary vein/coronary sinus. The very gentle debridement rendered by the ultrasonic aspirator makes it a valuable tool that I continue to use and recommend. Its ability to pulverize selectively the hard calcified tissue without injuring soft tissue permits safely attaining complete pliability in the annular region. As Feindel and colleagues1 made clear, a major concern of any procedure to remove the MAC is the potential of AV separation, and considerable care must be taken in the reconstitution of this area.
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References
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- Feindel CM, Zafar J, David TE, Ivanof J, Armstrong S. Mitral valve surgery in patients with extensive calcification of the mitral annulus. J Thorac Cardiovasc Surg. 2003;126:777–782[Abstract/Free Full Text]
- Vander Salm TJ. Mitral annular calcification: a new technique for valve replacement. Ann Thorac Surg. 1989;48:437–439[Abstract]
- Vander Salm TJ, Perras M. 1989: Mitral annular calcification: a new technique for valve replacement. Updated in 1997. Ann Thorac Surg. 1997;63:1819–1820[Free Full Text]
- Carpentier AF, Pellerin M, Fuzellier JF, Relland JY. Extensive calcification of the mitral valve annulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996;111:718–729 (discussion 729-3)[Abstract/Free Full Text]
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