Complete excision of mitral annular calcification and double valve replacement with aortomitral curtain reconstruction

Central MessageAortomitral curtain reconstruction for mitral annular calcification excision and double-valve replacement should be used in select elderly patients who do not qualify for transcatheter approach.See Commentary on page XXX.See Discussion on page XXX. Aortomitral curtain reconstruction for mitral annular calcification excision and double-valve replacement should be used in select elderly patients who do not qualify for transcatheter approach. See Commentary on page XXX. See Discussion on page XXX. This is a case of an 84-year-old woman who presented with symptomatic severe calcific mitral stenosis, moderate-to-severe mitral regurgitation, mitral annular calcification, moderate aortic stenosis, and moderate aortic insufficiency. The patient provided verbal consent for publication of study data, and institutional review board approval was not required. Transesophageal echocardiograph and transcatheter aortic valve replacement computed tomography measurements included left ventricular ejection fraction of 77%; severe extensive anterior and posterior mitral annular calcification (MAC) (MAC score1Guerrero M. Wang D.D. Pursnani A. et al.A cardiac computed tomography–based score to categorize mitral annular calcification severity and predict valve embolization.JACC Cardiovasc Imaging. 2020; 13: 1945-1957https://doi.org/10.1016/j.jcmg.2020.03.013Crossref PubMed Scopus (103) Google Scholar 10), severe mitral stenosis and regurgitation with peak/mean gradients 22/9 mm Hg; mild-moderate aortic insufficiency with mean gradient 25 mm Hg; aortic annulus diameter 18.3 × 16.0 mm, circumference 56.6 mm, and area 2.35 cm2; aortic valve calcium score 596; sinuses 26.9 × 24.1 × 26.2 mm (left, right, noncoronary – opposite commissure). With a height of 149 cm and weight of 60 kg, the patient's body surface area was 1.58 m2. The effective orifice area (EOA) necessary to avoid patient-prosthesis mismatch (PPM) for the aortic valve replacement was >1.34 cm2, and to avoid severe PPM was >1.03 cm2. The EOA necessary to avoid PPM for the mitral valve replacement was >1.9 cm2, and to avoid severe PPM was >1.42 cm2. Due to her anatomy, the patient was not a candidate for transcatheter valve replacement, and was therefore taken to the operating room for aortic and mitral valve replacement. Intraoperatively, the aortic annulus was too small to fit even the 19-mm sizer. The decision was made to proceed with a complete excision of MAC as previously described,2Shi W.Y. Mohan N. Sundt T.M. et al.Complete excision of mitral annular calcification can be achieved with a low mortality risk.Ann Thorac Surg Short Rep. 2023; 1: 34-39https://doi.org/10.1016/j.atssr.2022.08.002Abstract Full Text Full Text PDF Google Scholar and double valve replacement (DVR) with aortomitral curtain reconstruction, or so-called Commando operation (Video 1). Although more technically challenging and with notable operative risk,3David T.E. Gavra G. Feindel C.M. Regesta T. Armstrong S. Maganti M.D. Surgical treatment of active infective endocarditis: a continued challenge.J Thorac Cardiovasc Surg. 2007; 133: 144-149https://doi.org/10.1016/j.jtcvs.2006.08.060Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar,4Sheikh A.M. Elhenawy A.M. Maganti M. Armstrong S. David T.E. Feindel C.M. Outcomes of double valve surgery for active infective endocarditis.J Thorac Cardiovasc Surg. 2009; 138: 69-75https://doi.org/10.1016/j.jtcvs.2008.11.049Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar MAC excision with DVR and aortomitral curtain reconstruction eliminates the need to place mitral annular sutures through the calcified annulus and can allow for larger valve placement than DVR alone.5Perri J.L. Johnston D.R. Commando procedure in a radiated chest.J Thorac Cardiovasc Surg Tech. 2022; 15: 54-57https://doi.org/10.1016/j.xjtc.2022.07.006Abstract Full Text Full Text PDF Scopus (4) Google Scholar Indeed, this allowed placement of a 21-mm bovine pericardial aortic valve bioprosthesis (EOA, 1.4 ± 0.4 cm2) and a 29-mm porcine mitral valve bioprosthesis (EOA, 1.7 ± 0.1 cm2). Post-bypass echocardigram demonstrated no paravalvular leaks, and peak/mean gradients were 21/9 mm Hg for the aortic valve replacement and 8/3 mm Hg for the mitral valve replacement. The patient required pacemaker placement for intraventricular conduction delay, but otherwise recovered well, was discharged on postoperative day 13, and had returned to her preoperative functional status at her 1 month follow-up appointment. This case demonstrates that MAC excision with aortomitral curtain reconstruction to accommodate DVR is feasible in select cases of high-risk patients who do not qualify for the less-invasive transcatheter approach. Furthermore, division of aortomitral curtain greatly facilitates MAC debridement and patch reconstruction of the posterior annulus while allowing surgeons to upsize both valve prostheses. However, this is a very complex operation with extreme operative risk and should be reserved for senior surgical expertise when no further alternatives are available. You can watch a Webcast of this AATS meeting presentation by going to: https://www.aats.org/resources/complete-excision-of-mitral-an-7231. Dr Melnitchouk is a consultant to Medtronic. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiMTUxZDgwZDY5Zjg1MWUzOWE2ZDJmYTE0MzYwZjk1OSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzIzOTg0NjE1fQ.BYttNBEbozk-HMmOIyzpWdqwIxVZyj3yRvTPfw48xyx_3NM88nnLY6gl7nPbelA2WOjix7l2jRrONj87qgIONS91n3oc1PAF0RRCNET_wir0vaJqPXf932XRx_8NCc8KYZWTXgdKO5stQEHu41uCylPzRyazeOKy25N1Xrtai_dlHK7VjzAV17hKCJumuHxLI2P_pARUxf7cd2o-ga24SeZv-BGLDwfKQzqU5UKwVXtzcjZ9TtwUmg9ArROnNgc01MDBn-82RpaSAlxaQQaJsgpStmnyG2ARSYAGTSuCV5H67zOoAt6-aFy59HF5ybzahkdspAMl0tRFcGPAbWrgJw Download .mp4 (145.5 MB) Help with .mp4 files Video 1The accompanying intraoperative recording demonstrates an oblique aortotomy for excision of the aortic valve, which was unable to fit a 19-mm sizer despite decalcification. A transseptal incision was then performed extending the right atrial incision onto the dome of the left atrium. The oblique aortotomy was connected through the left-noncoronary commissure onto the anterior leaflet and to the transseptal incision. The mitral leaflets were then detached, followed by complete decalcification of the mitral annulus to remove a bulky bar of calcium. Reconstruction included an autologous pericardial patch to cover the debrided area with chordal support, placement of the mitral valve with an attached bovine pericardial patch with 2 tongues for closing the dome of the left atrium, and for reconstructing the intervalvular fibrosa and aortic root. The aortic valve was placed before reconstructing the aorta. The patient was cooled to 30 °C and careful administration of both antegrade and retrograde (with purse string suture around the coronary sinus) cold blood cardioplegia were used throughout the case. Cardiopulmonary bypass time was 364 minutes, crossclamp time was 278 minutes. Video available at: https://www.jtcvs.org/article/S2666-2507(24)00321-3/fulltext. Download .jpg (.34 MB) Help with files Video 1The accompanying intraoperative recording demonstrates an oblique aortotomy for excision of the aortic valve, which was unable to fit a 19-mm sizer despite decalcification. A transseptal incision was then performed extending the right atrial incision onto the dome of the left atrium. The oblique aortotomy was connected through the left-noncoronary commissure onto the anterior leaflet and to the transseptal incision. The mitral leaflets were then detached, followed by complete decalcification of the mitral annulus to remove a bulky bar of calcium. Reconstruction included an autologous pericardial patch to cover the debrided area with chordal support, placement of the mitral valve with an attached bovine pericardial patch with 2 tongues for closing the dome of the left atrium, and for reconstructing the intervalvular fibrosa and aortic root. The aortic valve was placed before reconstructing the aorta. The patient was cooled to 30 °C and careful administration of both antegrade and retrograde (with purse string suture around the coronary sinus) cold blood cardioplegia were used throughout the case. Cardiopulmonary bypass time was 364 minutes, crossclamp time was 278 minutes. Video available at: https://www.jtcvs.org/article/S2666-2507(24)00321-3/fulltext.