Supra-annular (Intra-atrial) Mitral Valve Replacement in Patients with Extremely calcified Mitral Valve Annulus

Background: Mitral annulus calcification (MAC) prevalence is 3-9%. In 20% of these cases MAC extensively involves the ventricular myocardium and requires dangerous radical debridement or another intervention providing safety mitral valve replacement.

Objective: determine outcome of complex mitral valve replacement surgery in the presence of extremely calcified mitral valve annulus.

Methods: From April 2015 to September 2015, 7 patients with Extremely calcified mitral valve underwent mitral valve replacement using a “new annulus” creation technique for symptomatic native mitral valve disease (n= 6) and prosthetic paravalvular leakage (n=1). Calcium and thickened tissue was removed from the leaflets to create a free wide-open orifice between the left atrium and the left ventricle. Prosthetic valve was implanted into the “new mitral valve annulus” created in the pericardial patch sutured above the MV annulus.

Results: Mean implanted valve size was 28.4mm ± 1.4mm (27 – 31 mm). Predischarge mitral prosthetic gradient was 6.6 ± 2.9 mm Hg. There was 1 in-hospital death due to severe paravalvular leak in a patient with history of 6 MVR surgeries. There was no late mortality follow up period 250 ± 157 days. There was one acute kidney injury, no Permanent heart block requiring pacemaker insertion and one case of CVA. In discharge none of the patients had valve-related complications, none of patients required reoperation during follow-up.

Conclusions: Creation of the “new” mitral annulus is an extremely useful adjunct to help avoid dreaded complications of atrioventricular disruption or valve dehiscence. On the basis of our modest experience we believe that a prosthetic mitral valve can be safely secured into a newly created annulus with very acceptable operative mortality and morbidity as well as good long-term results.