Asian Cardiovasc Thorac Ann 2008;16:488-489
© 2008 Asia Publishing EXchange Ltd
Mitral Valve Replacement in Calcified Annulus Following Ring Annuloplasty
Simon Messer, MBChB,
Pankaj Saxena, DNB,
Marcia Mickelburgh, MBBS,
Homayoun Jalali, FRCS,
Igor E Konstantinov, MD
Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Australia
For reprint information contact: Igor E Konstantinov, MD, Tel: 61 8 9346 3333, Fax: 61 8 9346 2344, Email: igorkonst{at}hotmail.com, Department of Cardiothoracic Surgery and University of Western Australia, Nedlands, WA 6009, Australia.
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ABSTRACT
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We present a patient with persistent severe hemolysis following mitral valve repair which resolved after valve replacement with bioprosthesis. The posterior portion of the annuloplasty ring was retained due to severe calcifications of the posterior mitral valve annulus. All chordae were preserved to avoid disruption of the mitral annulus.
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INTRODUCTION
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Mitral valve replacement in severely calcified mitral annulus is difficult, particularly following prior surgery on the mitral valve. To avoid direct suture placement through the fragile mitral annulus, an alternative technique has been described1,2 which utilizes the placement of suture through the full-thickness of the adjacent autologous tissue. It is effective in both repairing the periprosthetic leak and replacing of the prosthesis entirely.1–3 A strip of pericardium or Teflon is often useful to evenly distribute stress to the fragile annulus.1–3 Herein we describe a case where the posterior portion of previously placed mitral annuloplasty ring was retained and provided secure support for suture placement during implantation of the mitral prosthesis.
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CASE REPORT
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An 82-year-old female with rheumatic mitral valve disease underwent successful mitral valve annuloplasty with a 31-mm Duran ring. This provided good results although the posterior mitral annulus was stiff and severely calcified with the calcification extending into the ventricular aspect of the mitral valve (Figure 1A
). Postoperative course was uneventful. However, 4 months after the surgery, she became increasingly fatigued and was diagnosed with hemolytic anemia which required multiple transfusions. Echocardiography demonstrated mild mitral insufficiency with posteriorly directed high frequency jet of mitral insufficiency, therefore the mechanical hemolysis on the ring was suspected. The annuloplasty ring was seen well seated without any dehiscence. The patient underwent mitral valve replacement with a 25-mm Mosaic porcine prosthesis. The posterior portion of the annuloplasty ring was retained and the sutures were placed via the retained portion of the ring (Figure 1B). This secured the mitral prosthesis without the need for exposing the severely calcified mitral annulus. Postoperative echo confirmed normally functioning bioprosthetic valve. The patient had an uneventful recovery with complete resolution of the hemolysis. At 6 months after the operation, she was asymptomatic and had an excellent exercise tolerance.
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Figure 1. Chest Radiograph showing (A) severe calcification of the mitral annulus following mitral valve repair; (B) mitral valve replacement with the retained posterior portion of the annuloplasty ring.
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DISCUSSION
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Some patients may develop severe hemolysis following mitral valve repair and implantation of a mitral annuloplasty ring. Although the mechanism of such hemolysis is not entirely clear, the high-frequency jet of the residual mitral insufficiency may produce hemolysis when directed posteriorly against the annuloplasty ring. Mitral valve replacement is generally advised for persistent severe hemolysis after mitral valve repair.4
Although our patient had a hemodynamically insignificant mitral regurgitation following the repair, the posterior leaflet was restrictive (Carpentier Type III abnormality). As a result, the regurgitation jet was directed posteriorly onto the annuloplasty ring. We felt that it was not possible to repair the mitral valve well enough to eliminate the cause of the hemolysis. Thus, mitral valve replacement was carried out. Furthermore, we did not excise any leaflet tissue or subvalvular apparatus. Plication of the valve leaflets to the annulus was performed to avoid interference of the native valve tissue with the bioprosthetic valve function.
Severe calcification of the mitral annulus further complicated surgical approach in our patient, as there would be no strong tissue to securely hold the stitches following the removal of the posterior portion of the annuloplasty ring with calcium debridement. This severe calcification of the mitral annulus encountered at reoperation was a very worrisome sign as the disruption of the fragile mitral annulus may develop into left ventricular rupture – one of the most dreadful complications of cardiac surgery. Although the incidence of the LV rupture, according to a recent study,5 was only 0.24%, it was associated with mortality of 61.5%.
The technique described herein may not be applicable to all the cases of failed annuloplasty. Theoretically, there could be an abnormal bending of the mitral valve sewing ring that may lead to postoperative mitral insufficiency. If there was no calcification of the mitral annulus, we would explant the ring and suture the new prosthesis to valve annulus in the conventional fashion. However, the approach outlined in this report might be useful in preventing disruption of severely calcified mitral annulus during valve replacement following previous annuloplasty.
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REFERENCES
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- Konstantinov IE, Franzen SF, Olin CL. Periprosthetic leaks and valve dehiscence: alternative methods of repair. J Heart Valve Dis 1997;6:281–7.[Medline]
- Konstantinov IE. A new technique for repair of mitral paravalvular leak? J Thorac Cardiovasc Surg 2005;130:614–5.[Free Full Text]
- Konstantinov IE, Carter M, Saxena P, Koniuszko M, Singh T, Alvarez J, et al. Prosthesis replacement in calcified mitral annulus with reconstruction of the intervalvular fibrous body: the value of alternative repair. Tex Heart Inst J 2006;33:232–4.[Medline]
- Lam BK, Cosgrove DM, Bhudia SK, Gillinov AM. Hemolysis after mitral valve repair: mechanisms and treatment. Ann Thorac Surg 2004;77:191–5.[Abstract/Free Full Text]
- Zhang HJ, Ma WG, Xu JP, Hu SS, Zhu XD. Left ventricular rupture after mitral valve replacement: a report of 13 cases. Asian Cardiovasc Thorac Ann 2006;14:26–9.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
