Double-layer horizontal cross sutures for intra-atrial mitral valve implantation: An effective surgical method for severe mitral annular calcification

Mitral valve replacement in severe mitral annular calcification.

Figure 1. Study design: summary of inclusion and exclusion criteria. MVR, Mitral valve replacement; MAC, mitral annular calcification; EF, ejection fraction; EGFR, estimated glomerular filtration rate; DL, double layer; SL, single layer; PVL, perivalvular leakage.

Figure 2. Representative patterns of severe MAC in patients with symptomatic MR. Images from gated, contrast-enhanced cardiac computed tomography are shown. A, Severe mitral annular calcification. B, Severe aortic annular calcification. Mitral annulus complete calcification often coexists with aortic annular calcification. AO, Aorta; MV, mitral valve; AV, aortic valve.

Figure 3. Surgical procedures for partial mitral annular calcification. A, Mitral valve with severe partial annular calcification. B, The anterior leaflet is resected, and the posterior leaflet and its attached chordae are preserved. C, Double-layer horizontal cross suture is performed in the calcified part of the mitral annulus, which can be divided into 2 steps. First, horizontal mattress sutures are placed in the left atrial wall approximately 2 mm lateral to the calcified annulus. D, Next, pledgeted mattress sutures are placed on each side of the midline of the first layer of suture to overlap the interval between them.

Figure 4. Graphic abstract: double-layer horizontal cross-suture technique for mitral valve implantation in patients with severe mitral annular calcification. AO, Aorta; MV, mitral valve; PVL, perivalvular leakage; MAC, mitral annular calcification.

Figure E1. Surgical procedures for posterior mitral annular calcification. A, Mitral valve with severe posterior annular calcification. B, The anterior leaflet is resected, and the posterior leaflet and its attached chordae are preserved. C, Double-layer horizontal cross suture is performed in the calcified part of the mitral annulus, which can be divided into 2 steps. First, horizontal mattress sutures are placed in the left atrial wall approximately 2 mm lateral to the calcified annulus. D, Next, pledgeted mattress sutures are placed on each side of the midline of the first layer of suture to overlap the interval between them.

Figure E2. Surgical procedures for entire mitral annular calcification. A, Mitral valve with severe entire annular calcification. B, The aortic annulus and aortomitral curtain calcification were removed first using a previously reported fibrosa layer stripping technique. C, Fix the Dacron patch to it as the starting segment for suturing.

Figure E3. Survival curve for DL and SL suture group. MVR, Mitral valve replacement; MAC, mitral annular calcification; SL, single layer; DL, double layer; CI, confidence interval.