Sage Journals: Discover world-class research

Abstract

Objective:

Minimally invasive surgery for mitral annular calcification (MAC) has been reported sporadically, but data on endoscopic surgery are scarce. We summarize current surgical understanding of MAC and how it applies to endoscopic surgery through our experience.

Methods:

All patients with severe MAC undergoing endoscopic mitral surgery at a single institution (December 2020 to August 2024) were studied.

Results:

Twenty-five patients (3 female patients) with an average left ventricular ejection fraction of 52.12% (46.25% to 60%), average age of 69.13 (64 to 75.7) years, average body surface area of 1.92 (1.69 to 2.09) m², and average Society of Thoracic Surgeons predicted risk of mortality score of 8.30% (2.13% to 8.66%) underwent endoscopic surgery. Twelve patients had regurgitation (48%), 10 had stenosis (48%), and 3 had a combination (12%). Circumferential MAC was found in 4 patients (16%), 80% circumference in 7 (28%), 60% circumference in 7 (28%), and 40% circumference in 7 (28%). Mitral valve replacement was done in 72% (n = 18) with tissue valves (n = 11), mechanical valves (n = 4), or transcatheter balloon-expandable valves (n = 3). Seven patients (28%) had repairs. There were no operative deaths, atrioventricular complications, or strokes. The average duration of surgery was 5 h 40 min (4 h 13 min to 8 h 22 min), with average cardiopulmonary bypass and cross-clamp times of 214 (166 to 241) min and 152 (117 to 193) min, respectively. MAC was debrided in 20 patients with ultrasonic emulsification (n = 13) or mechanical debridement (n = 7).

Conclusions:

Endoscopic surgery for severe MAC can be safely and successfully performed using a combination of surgical techniques including ultrasonic decalcification, mechanical debridement, annular patching, and direct implantation of balloon-expandable valves.

Visual abstract

Keywords

mitral annular calcification mitral valve regurgitation mitral valve stenosis endoscopic mitral surgery endoscopic cardiac surgery minimally invasive mitral surgery mitral valve repair mitral valve replacement

Get full access to this article

View all access options for this article.

References

Gammie

Zhao

Peterson

, et al. J Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less invasive mitral valve operations: trends and outcomes from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2010; 90: 1401–1410.

Baumgartner

Falk

Bax

, et al. 2017 ESC/EACTS guidelines for management of valvular heart disease. Eur Heart J 2017; 30: 2739–2791.

Paparella

Fattouch

Moscarelli

, et al. Current trends in mitral valve surgery: a multicenter national comparison between full-sternotomy and minimally-invasive approach. Int J Cardiol 2020; 306: 147–151.

Dogan

Aybek

Risteski

, et al. Minimally invasive port access versus conventional mitral valve surgery: prospective randomized study. Ann Thorac Surg 2005; 79: 492–498.

Sündermann

Sromicki

Rodriguez Cetina Biefer

, et al. Mitral valve surgery: right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2014; 148: 1989–1995.

Modi

Hassan

and Chitwood

Jr.

Minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2008; 34: 943–952.

Akowuah

Maier

Hancock

, et al. Minithoracotomy vs conventional sternotomy for mitral valve repair: a randomized clinical trial. JAMA 2023; 329: 1957–1966.

Barasch

Gottdiener

Larsen

, et al. Clinical significance of calcification of the fibrous skeleton of the heart and aortosclerosis in community dwelling elderly. The Cardiovascular Health Study (CHS). Am Heart J 2006; 151: 39–47.

Fann

Ingels

Jr and Miller

Pathophysiology of mitral valve disease. In: Cohn

Adams

(eds) Cardiac surgery in the adult. 5th ed. New York: McGraw-Hill, 2018.

10.

Abramowitz

Jilaihawi

Chakravarty

, et al. Mitral annulus calcification. J Am Coll Cardiol 2015; 66: 1934–1941.

11.

Fox

Vasan

Parise

, et al. Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study. Circulation 2003; 107: 1492–1496.

12.

Barasch

Gottdiener

Marino Larsen

, et al. Cardiovascular morbidity and mortality in community-dwelling elderly individuals with calcification of the fibrous skeleton of the base of the heart and aortosclerosis (The Cardiovascular Health Study). Am J Cardiol 2006; 97: 1281–1286.

13.

Benjamin

Plehn

D’Agostino

, et al. Mitral annular calcification and the risk of stroke in an elderly cohort. N Engl J Med 1992; 327: 374–379.

14.

Kizer

Wiebers

Whisnant

, et al. Mitral annular calcification, aortic valve sclerosis, and incident stroke in adults free of clinical cardiovascular disease: the Strong Heart Study. Stroke 2005; 36: 2533–2537.

15.

Fox

Parise

Vasan

, et al. Mitral annular calcification is a predictor for incident atrial fibrillation. Atherosclerosis 2004; 173: 291–294.

16.

O’Neal

Efird

Nazarian

, et al. Mitral annular calcification and incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis. Europace 2015; 17: 358–363.

17.

Kanjanauthai

Nasir

Katz

, et al. Relationships of mitral annular calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2010; 213: 558–562.

18.

Hamirani

Nasir

Blumenthal

, et al. Relation of mitral annular calcium and coronary calcium (from the Multi-Ethnic Study of Atherosclerosis [MESA]). Am J Cardiol 2011; 107: 1291–1294.

19.

Higgins

Mayo

and Skarsgard

Cardiac computed tomography facilitates operative planning in patients with mitral calcification. Ann Thorac Surg 2013; 95: e9–e11.

20.

Blanke

Naoum

Dvir

, et al. Predicting LVOT obstruction in transcatheter mitral valve implantation. JACC Cardiovasc Imaging 2017; 10: 482–485.

21.

Murphy

Don

, et al. Use of cardiac computerized tomography to predict neo-LVOT ventricular outflow tract obstruction before transcatheter mitral valve replacement. J Am Heart Assoc 2017; 6: e007353.

22.

Guerrero

Grayburn

Smith

2nd , et al. Diagnosis, classification, and management strategies for mitral annular calcification: a Heart Valve Collaboratory Position Statement. JACC Cardiovasc Interv 2023; 16: 2195–2210.

23.

Thanassoulis

Campbell

Owens

, et al. Genetic associations with valvular calcification and aortic stenosis. N Engl J Med 2013; 368: 503–512.

24.

Carpentier

Pellerin

Fuzellier

, et al. Extensive calcification of the mitral valve anulus: pathology and surgical management. J Thorac Cardiovasc Surg 1996; 111: 718–730.

25.

David

Feindel

Armstrong

, et al. Reconstruction of the mitral anulus: a ten-year experience. J Thorac Cardiovasc Surg 1995; 110: 1323–1332.

26.

Ben-Avi

Orlov

Sternik

, et al. Short- and long-term results after prosthetic mitral valve implantation in patients with severe mitral annulus calcification. Interact Cardiovasc Thorac Surg 2017; 24: 876–881.

27.

Salhiyyah

Kattach

Ashoub

, et al. Mitral valve replacement in severely calcified mitral valve annulus: a 10-year experience. Eur J Cardiothorac Surg 2017; 52: 440–444.

28.

Abramowitz

Jilaihawi

Chakravarty

, et al. Mitral annulus calcification. J Am Coll Cardiol 2015; 66: 1934–1941.

29.

Allison

Cheung

Criqui

, et al. Mitral and aortic annular calcification are highly associated with systemic calcified atherosclerosis. Circulation 2006; 113: 861–866.

30.

Kanjanauthai

Nasir

Katz

, et al. Relationships of mitral annular calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2010; 213: 558–562.

31.

MacVaugh

Joyner

and Johnson

Unusual complications during mitral valve replacement in the presence of calcification of the annulus. Ann Thorac Surg 1971; 11: 336–342.

32.

Okada

Surgical management of mitral annular calcification. Gen Thorac Cardiovasc Surg 2013; 61: 619–625.

33.

Fusini

Ghulam Ali

Tamborini

, et al. Prevalence of calcification of the mitral valve annulus in patients undergoing surgical repair of mitral valve prolapse. Am J Cardiol 2014; 113: 1867–1873.

34.

Kaneko

Hirji

Percy

, et al. Characterizing risks associated with mitral annular calcification in mitral valve replacement. Ann Thorac Surg 2019; 108: 1761–1767.

35.

Uchimuro

Fukui

Shimizu

, et al. Mitral valve surgery in patients with severe mitral annular calcification. Ann Thorac Surg 2016; 101: 889–895.

36.

Feindel

Tufail

David

, et al. Mitral valve surgery in patients with extensive calcification of the mitral annulus. J Thorac Cardiovasc Surg 2003; 126: 777–778.

37.

Chan

Ruel

Hynes

, et al. Impact of mitral annular calcification on early and late outcomes following mitral valve repair of myxomatous degeneration. Interact Cardiovasc Thorac Surg 2013; 17: 120–125.

38.

Otto

Nishimura

Bonow

, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77: 450–500.

39.

Brescia

Rosenbloom

Watt

TMF

, et al. Ultrasonic emulsification of severe mitral annular calcification during mitral valve replacement. Ann Thorac Surg 2022; 113: 2092–2096.

40.

Barbero

Spitaleri

Pocar

, et al. Handling extensive mitral annular calcification via a minimally invasive right mini-thoracotomy approach. Appl Sci 2023; 13: 2563.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

2.10 MB

9.65 MB

7.78 MB

Totally Endoscopic Management of Mitral Annular Calcification: A Single-Center Experience

Abstract

Objective:

Methods:

Results:

Conclusions:

Keywords

Get full access to this article

References

Supplementary Material