Use of annulus washer after debridement: A new mitral valve replacement technique for patients with severe mitral annular calcification

Extreme calcification of the mitral annulus (MAC) is a formidable challenge during mitral valve surgery, with the risk of serious and potentially fatal complications such as stroke, atrioventricular disruption, ventricular rupture, valve dehiscence, and periprosthetic leakage.1Cammack Pl Edie R.N. Edmunds Jr., L.H. Bar calcification of the mitral annulus: a risk factor in mitral valve operations.J Thorac Cardiovasc Surg. 1987; 94: 399-404Abstract Full Text PDF PubMed Google Scholar A variety of surgical techniques have been developed that vary from avoiding or minimizing any decalcification2Grossi E.A. Galloway A.C. Steinberg B.M. Leboutillier III, M. Delianides J. Baumann F.G. et al.Severe calcification does not affect long-term outcome of mitral valve repair.Ann Thorac Surg. 1994; 58: 685-688Abstract Full Text PDF PubMed Scopus (30) Google Scholar to extensive radical removal of the calcium bar followed by reconstruction of the atrioventricular annulus.3Carpentier A.F. Pellerin M. Fuzellier J.F. Relland J.Y. Extensive calcification of the mitral valve annulus: pathology and surgical management.J Thorac Cardiovasc Surg. 1996; 111: 718-730Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar, 4David T.E. Feindel C.M. Armstrong S. Sun Z. Reconstruction of the mitral annulus: a ten-year experience.J Thorac Cardiovasc Surg. 1995; 110: 1323-1332Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 5Feindel C.M. Tufail Z. David T.E. Ivanov J. Armstrong S. Mitral valve surgery in patients with extensive calcification of the mitral annulus.J Thorac Cardiovasc Surg. 2003; 126: 777-782Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar We describe our experience with an intermediate approach that involves limited debridement of the calcified annulus, allowing implantation of a good-sized prosthesis using a felt washer, sandwiched between the annulus and prosthesis, as a support. From August 2006 to October 2011, 20 patients with severe MAC underwent mitral valve replacement using the polytetrafluoroethylene (PTFE) washer technique for symptomatic native mitral valve disease (n = 17), periprosthetic leakage (n = 2), and systolic anterior motion of the anterior mitral valve leaflet after myectomy (n = 1). Mean age was 75 ± 18 years (range, 51-87 years). Eleven patients predominantly had regurgitation, 5 had stenosis, and 4 had both. Thirty-one concomitant procedures were performed in 20 patients (Table 1). The study was approved by the Institutional Review Board of the Cleveland Clinic, with patient consent waived.Table 1Preoperative patient characteristics and operative details (n = 20)VariableNo.Patient characteristics DemographyAge (y), mean ± SD75 ± 18Female15 Mitral valve diseaseDegenerative10Hypercalcemia, after renal transplant2After radiation2Periprosthetic leakage2HOCM/SAM2Rheumatic heart disease2 ComorbiditiesHypertension15Coronary artery disease10Prior CABG3Renal insufficiency7Diabetes mellitus5 History of cardiac operationsPrior cardiac operation8Reoperation8142331Prior mitral valve replacement2Operative details Prosthetic valve type and sizeBioprosthetic tissue valve18No. 254No. 276No. 297No. 311Mechanical valve2No. 231No. 311 Concomitant procedures31Aortic valve replacement10Aortic valve repair1CABG6Tricuspid valve repair5Aortic root replacement3Maze procedure3Myectomy3SD, Standard deviation; HOCM, hypertrophic obstructive cardiomyopathy; SAM, systolic anterior motion; CABG, coronary artery bypass grafting. Open table in a new tab SD, Standard deviation; HOCM, hypertrophic obstructive cardiomyopathy; SAM, systolic anterior motion; CABG, coronary artery bypass grafting. Conventional full median sternotomy, standard cannulation (except in 1 patient in whom the axillary artery was cannulated because of extensive aortic calcification), and normothermic cardiopulmonary bypass were used in all patients. The mitral valve is approached transeptally. First the severity of the disease and valvular dysfunction is reevaluated to finalize the surgical plan. This includes sizing the valve opening and estimating the debridement necessary to implant a good-sized valve. Exposure is optimized with a low threshold to extend the atrial septal incision to the dome of the left atrium and add a proximal aortotomy. The anterior leaflet is preserved and transposed posteriorly to support the annulus, and when doable, the posterior leaflet is released and also salvaged for support. Debridement is performed carefully piece by piece by rongeur, often using a dual approach from the left atrium and aortic root. Great care is taken to avoid transmural defects in the atrioventricular groove or deep defects in the posterior wall muscle. Size and shape of the mitral opening are repeatedly reevaluated until it is deemed possible to place sutures and implant a prosthesis of good size. In some cases this requires extensive debridement. The valve sutures are placed through or around the residual calcium and annulus, with pledgets on the ventricular side (Figure 1, A). Working through the aortotomy often allows better placement of valve sutures in the region of the central fibrous body. A 1- to 1.5-cm wide (1/2 inch) PTFE felt washer is inserted in between the annulus and sewing ring of the prosthesis from trigone to trigone posteriorly (Figure 1, B). The valve and the washer are tied down. The washer is then sutured to the atrial wall with a second suture line using running No. 4-0 polypropylene (Figure 1, C). Generous irrigation is performed repeatedly to clear the heart of loose pieces of calcium. Mean implanted valve size was 27 mm (range, 23-31 mm; Table 1). Predischarge mitral prosthetic gradient was 5.0 ± 3.0 mm Hg. At a mean follow-up of 8 months (range, 2-60 months), there were no periprosthetic leaks or valve-related reinterventions. One hospital death occurred after 60 days as a result of multisystem organ failure and sepsis in a renal transplant patient with preexisting severe pulmonary hypertension. One patient required reexploration for chest wall bleeding, and 2 had transient neurologic deficits. Actuarial survival was 50% at 5 years, with 5 late noncardiac deaths. Current techniques described in the literature2Grossi E.A. Galloway A.C. Steinberg B.M. Leboutillier III, M. Delianides J. Baumann F.G. et al.Severe calcification does not affect long-term outcome of mitral valve repair.Ann Thorac Surg. 1994; 58: 685-688Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 3Carpentier A.F. Pellerin M. Fuzellier J.F. Relland J.Y. Extensive calcification of the mitral valve annulus: pathology and surgical management.J Thorac Cardiovasc Surg. 1996; 111: 718-730Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar, 4David T.E. Feindel C.M. Armstrong S. Sun Z. Reconstruction of the mitral annulus: a ten-year experience.J Thorac Cardiovasc Surg. 1995; 110: 1323-1332Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 5Feindel C.M. Tufail Z. David T.E. Ivanov J. Armstrong S. Mitral valve surgery in patients with extensive calcification of the mitral annulus.J Thorac Cardiovasc Surg. 2003; 126: 777-782Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar involve either extensive calcium debridement and annular reconstruction, risking ventricular rupture and bleeding, or a conservative approach and use of a small-sized prosthesis, at the risk of periprosthetic leakage. Our technique is designed to allow implantation of a good-sized prosthesis with low risk of ventricular rupture and periprosthetic leak. Risk of ventricular rupture is minimized by debriding only enough calcium to make room for the prosthesis, leaving some calcium and the capsule posteriorly. Sandwiching a PTFE felt washer between the valve ring and annulus offers additional support, and its attachment to the atrium with a running suture provides a good seal, decreasing risk of periprosthetic leakage. The dual approach, working through the atrium and the aortic valve, is very helpful. This approach, with limited calcium debridement and use of a sandwiched felt washer, is a new, easier, and possibly safer way to implant an acceptably sized mitral prosthesis in patients with severe MAC. Notice of CorrectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 152Issue 1PreviewRe: Hussain ST, Idrees J, Brozzi NA, Blackstone EH, Pettersson GB. Use of annulus washer after debridement: a new mitral valve replacement technique for patients with severe mitral annular calcification. J Thorac Cardiovasc Surg. 2013;145:1672-4. Full-Text PDF Open ArchiveMitral valve replacement in the presence of massive calcificationThe Journal of Thoracic and Cardiovascular SurgeryVol. 146Issue 5PreviewI was pleasantly surprised to read the novel technique reported by Hussain and colleagues.1 I reported on the technique used at the All India Institute of Medical sciences way back in 1988,2 which my group used when confronted with a heavily calcified mitral annulus. We used a piece of autologous pericardium to cover the raw surface of the brittle and sandy remnant after limited débridement of calcium and to prevent calcific emboli. This patient was followed up and seen again in 2001, at which time I reported the favorable result of 13 years free of embolism. Full-Text PDF Mitral valve replacement in heavily calcified posterior annulusThe Journal of Thoracic and Cardiovascular SurgeryVol. 146Issue 6PreviewI read with extreme interest the article by Hussain and colleagues1 published in a recent issue of the Journal, describing their results in patients with severe mitral annular calcification undergoing mitral valve replacement (MVR). Full-Text PDF