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Ann Thorac Surg 2000;70:53-58
© 2000 The Society of Thoracic Surgeons

Original articles: Cardiovascular

Valve repair in mitral regurgitation complicated by severe annulus calcification

Choi-Keung Ng, MDa, Christian Punzengruber, MDb, Otmar Pachinger, MDc, Joachim Nesser, MDb, Hannes Auer, MDb, Herbert Franke, MDa, Peter Hartl, MDa

a Department of Cardiovascular Surgery, General Hospital Wels, Wels, Austria
b Department of Cardiology, General Hospital Wels, Wels, Austria
c Department of Cardiology, University Clinic Innsbruck, Innsbruck, Austria

Address reprint requests to Dr Ng, Department of Cardiovascular Surgery, General Hospital Wels, Grieskirchnerstr 42, A-4600 Wels/OOe, Austria


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Valvuloplasty has significant advantages over valve replacement for mitral regurgitation, but the presence of severe calcification of the mitral valve apparatus has been thought to preclude successful valve reconstruction in general. The purpose of this report is to assess the results of valvuloplasty in patients with severe mitral regurgitation having extensive calcification extending from the mitral annulus to underlying myocardium and parts of the papillary muscles.

Methods. Thirty-seven adult patients with severe mitral regurgitation and calcification were operated on between April 1990 and January 1998. Twenty-six patients had degenerative disease, 4 had acute bacterial endocarditis, 6 had postrheumatic fever, and 1 patient had Marfan’s disease. The valve repair comprised of en bloc decalcification with extensive leaflet debridement and reconstruction of the annulus. Autologous pericardium was used in patch-extended endocardial annuloplasty or leaflet repair. Valve competence was retained after correction of regurgitation by sliding atrioplasty, rotation paracommissural sliding plasty, cusp remodeling, or chordal repair. All patients required a prosthetic annuloplasty.

Results. Follow-up echocardiography at 47 months (range, 3 to 92 months) showed no or only trivial mitral regurgitation in 33 patients; 3 had grade I–II mitral regurgitation and 1 required valve replacement after 3 months. Freedom of reoperation at 1 and 5 years was 94.6%. At last examination, 33 patients were in New York Heart Association functional class I and 3 in class I–II; there has been no mortality and no thromboembolic events.

Conclusions. Valvuloplasty can be safely and successfully carried out in patients suffering from regurgitation associated with severe calcification of the mitral apparatus. With encouraging beneficial midterm results, we suggest patients with calcified valves should not be excluded from mitral repair.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Mitral annular calcification, if sufficiently extensive, prevents systolic contraction of the atrioventricular (AV) annulus. The dense calcification of the entire submitral region in its most severe form, is a rigid curved bar or ring of calcium that encircles the mitral orifice (Fig 1C), and calcific spurs may project into the adjacent left ventricular myocardium. The calcification may involve the basal portion of the valve leaflets and causes distortion of the posterior mitral valve leaflet with limitation of motion. The base of the posterior cusp is pushed up toward the atria, often stimulating a degree of mitral prolapse. This may result in insufficient leaflet area for coaptation, leading to regurgitation and congestive failure if untreated. Mitral insufficiency can be severe, found with ruptured chordae tendineae or with severely elongated chordae billowing into the atrium (Fig 1A). Although mild to moderate mitral regurgitation (MR) is the usual functional consequence of submitral calcium mass, an obstructive gradient across the mitral valve during the diastole may be found occasionally. Anatomic distortion of the valve may predispose to endothelial injury, necrosis, infection, and thrombus or vegetation formation. Mitral annular calcification was found to be associated with a significant risk of emboli stroke, with atrial fibrillation perhaps the most important cause [1]. Other known complications include development of bacterial endocarditis as the calcific masses ulcerate onto the endocardial surface and an incidence of AV block as calcium extends into the ventricular septum. Secondary mechanical injury often referred as Lev’s disease (as calcium encroaches on the bundle of His) is associated with intraventricular conduction abnormalities and symptomatic AV block [2].



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  		Fig 1. (A) Severe mitral valve calcification with leaflets prolapse on transesophageal echocardiogram; arrow indicates annulus calcification with extension to the myocardium, chordae, and papillary muscle. (B) Calcified chordae and papillary muscle excised. (C) Calcified annulus (4.9 cm) after en bloc resection. (D) Pretreated autologous pericardial patch extended annuloplasty.

 
Valve repair for treatment of mitral regurgitation has definite advantages over replacement; that is, reconstruction has a lower likelihood of thromboembolism, anticoagulant-related hemorrhage, hemolysis, and infectious endocarditis. Mitral valvuloplasty with preservation of annular–chordal–papillary muscle continuity results in maintenance of left ventricular systolic function, lower left ventricular volumes, less end-systolic wall stress, and has a lower mortality than mitral valve replacement [3, 4]. However, degenerative and rheumatic mitral valve disease often associated with severe calcification of the annulus, leaflets, and subvalvular mechanism may preclude a successful result [5–8]. The aim of our study was to evaluate the results of applying several surgical strategies to the repair of MR in patients with heavily calcified mitral valves.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patients and operation
The study population consisted of 37 patients with extensive calcification of the mitral annulus and severe mitral insufficiency who were operated on in our department between April 1990 and January 1998. Table 1 summarizes the clinical profile of these patients. These individuals represented 8.4% of all patients undergoing reconstructive procedures during this time period. A preoperative transthoracic or transesophageal echocardiogram and coronary angiogram with left heart catheterization were performed in all patients. They had mean regurgitant grade of 3.5 of 4 and were in New York Heart Association functional class III or IV. Etiology of the mitral valve disease included degenerative disease in 27 patients (6 with Barlow’s disease), acute bacterial endocarditis in 4, postrheumatic fever in 6, and 1 patient with Marfan’s syndrome. Fifty-nine percent of patients were in atrial fibrillation, three of whom had previous strokes. Peripheral emboli due to acute endocarditis resistant to medical therapy had been found in 2 patients before operation. Two elderly patients were diagnosed with Lev’s disease, primarily suffering from Stokes-Adams attacks. Investigations demonstrated severe annular calcification and MR associated with AV and bundle branch block. Both patients were treated with physiologic pacemakers after successful valve repair. Six patients had coronary bypass grafting for incidental coronary disease. Five patients also underwent tricuspid valve reconstruction using DeVega annuloplasty for severe tricuspid regurgitation.


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  		Table 1. Clinical Profile of Patients

 
The procedures were performed using median sternotomy with bicaval cannulation and normothermic cardiopulmonary bypass. The use of normothermic techniques has been reported to confer several advantages over conventional hypothermia, such as reduced bleeding and requirements for electrical defibrillation, shorter intubation times, and improved hemodynamic parameters postoperatively [9]. Myocardial protection with cold antegrade and retrograde St. Thomas’ cardioplegic (II) solution was obtained. Coronary revascularization was carried out before exposure of the mitral valve. Segmental analysis of the mitral valve apparatus showed calcification with degenerative process involving at least one-third of the posterior annulus in 27 patients, and the entire posterior annulus in 4 patients. Calcification extending to the myocardial wall was found in 16 patients, and further into the papillary muscles in 9 patients. Dense commissural and leaflet calcification due to rheumatic heart disease was observed in 6 patients with mineralization to the posterior annulus and the attached chordae. Infected leaflets with vegetations were found in 4 of these patients.

Reconstructive technique
These massive calcifications often are encapsulated, covered by the endocardium. Decalcification was performed as an en bloc resection to prevent calcium fragmentation. We never used rongeur or ultrasound to debride calcium. Sharp dissection was used to incise the atrial endothelium around the borders of the calcified bar (Fig 1A–C). Meticulous attention with precise detachment and gentle handling of the tissue was taken to avoid disrupting the AV continuity, rupture of the ventricular wall during excision of the calcified papillary muscle tissue, and damage to the circumflex artery. All debris was carefully removed and the site was amply irrigated to minimize the risk of embolization. A quadrangular resection of the posterior leaflet was carried out, often combined with complete detachment from commissure to commissure. After en bloc decalcification of the annulus and the adjacent myocardium, two edges of fragile or fibrous tissue delimit the superior atrium and inferior ventricle. To reconstruct the annulus with "pericardial patch-extended endocardial annuloplasty," a strip of 0.62% glutaraldehyde-pretreated autologous pericardium [10] was tailored and its margins were sutured to the ventricular inflow endocardium or to fibrous skeleton of the heart, and posterior left atrial wall with a continuous 5-0 or 6-0 polytetrafluoroethylene suture. Defects created by the quadrangular leaflet resection in 12 patients were repaired by leaflet advancement. Leaflet reattachment and reapproximation at the appropriate level to the pericardial patch was carried out with a 6-0 or 7-0 polytetrafluoroethylene suture (Fig 1D).

We found that "sliding atrioplasty" [11] offered an alternative method of repair in 9 patients. After the atrium was dissected free of calcium, an atrial edge was mobilized to form a flap at the AV junction. To construct a new annulus, this flap was then used to cover the exposed underlying myocardium using gently tied multiple figure-of-eight 6-0 or 7-0 polytetrafluoroethylene vertical sutures. Appropriate annulus plication was added to form imbrication. After the sliding leaflet technique, the leaflet remnants were sutured to the reconstructed annulus (Fig 2a–c).



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  		Fig 2. (a) Leaflet and atrial edge mobilized after decalcification process. (b) Technique of sliding atrioplasty: left corner shows the two layers of tissue repaired with figure of eight vertical sutures, covered later with leaflet. (c) Completion of sliding atrioplasty. (d) Semiflexible annuloplasty ring (Sculptor) after implantation. Adequate ratio of vertical and transverse annulus diameter.

 
"Rotation paracommissural sliding plasty" [12] was used in 8 patients with calcified commissures. After resection of the mineralized or infected area, both anterior and posterior leaflets were detached from the annulus allowing them to slide to fill the resection defects and restore function. Mostly, the posterior leaflet was further mobilized, being incised along its annular attachment, followed with a few annular compression sutures to decrease the circumference. A new commissure was created by appropriate clockwise or counterclockwise rotation of the mobilized posterior leaflet, using an interscallop indentation as the new commissure. The cut leaflet edges were anastomosed. The indentation between scallops was well suited for this purpose because leaflet distortion was avoided due to preservation of functional chordal architecture (Fig 3L). A large annular plication was avoided in these patients and severe MR was immediately abolished (Fig 3R) with continued excellent follow-up results.



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  		Fig 3. (L) Technique of rotation paracommissural sliding plasty; after decalcification, arrow shows the direction where leaflets indentation will meet. (R) Perfect leaflet coaptation after rotation paracommissural sliding plasty.

 
A conventional posterior leaflet resection with sliding leaflet plasty was performed in the other 10 patients. The calcified papillary muscles and chordae found in 9 patients were resected (Fig 1B, C), followed by repair by chordal transfer in 6 patients with secondary chordae [13]. Prolonged chordae of anterior leaflets in 11 patients were shortened by invagination of their excess length in the papillary muscle [14]. In the other 3 patients with bileaflet prolapse, there were limited secondary chords suitable for chordal transfer after extended resection of the posterior leaflet. Insertion of artificial chordae with polytetrafluoroethylene sutures for chordal replacement [15] was achieved and anterior leaflet resection was avoided in them.

Appropriately sized annuloplasty rings were used to complete and preserve the mitral reconstruction in all patients. Rigid Carpentier-Edwards annuloplasty ring (Baxter Healthcare Corp, Irvine, CA) was used in 6 patients, the semiflexible Medtronic Sculptor annuloplasty ring (Medtronic, Minneapolis, MN)[16] was used in 24 patients (Fig 2D), and flexible Cosgrove-Edward (Baxter Healthcare Corp, Irvine, CA) annuloplasty ring [17] was implanted in 7 patients. After ring placement, valvular competence was directly assessed in the arrested heart by transvalvular infusion of saline. Simultaneously, retrograde cardioplegia with aorta venting was used to reduce the incidence of air embolism. Atriotomy closure, de-airing and decannulation were carried out in the standard fashion. The mean ischemic period in all patients was 127.1 ± 30.7 minutes, and extracorporeal circulation period was 181.8 ± 54.9 minutes.

Mitral valve function was assessed again by transesophageal echocardiogram after cessation of bypass. The transesophageal echocardiogram was performed in all patients before discharge to confirm adequacy of reconstruction. Postoperative warfarin anticoagulant therapy was instituted in all patients for the first 6 months. The reconstructive technique is listed in Table 2.


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  		Table 2. Reconstructive Technique

 

   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
The postrepair intraoperative transesophageal echocardiogram showed satisfactory results with no or trivial MR initially in all patients. There were no operative deaths, perioperative complications, or hospital mortality. Inotropic support for postoperative low cardiac output was required in 3 patients. Six patients were treated for renal dysfunction.

One 75-year-old patient required re-repair with remnant recoaptation because of suture rupture and hemolysis 4 weeks after initial successful operation. Another patient evidenced severe MR 3 months after the repair (from the early series) necessitating replacement of the dehisced ridged annuloplasty ring with a 29-mm St. Jude prosthesis (St. Jude Medical, St. Paul, MN).

Follow-up echocardiographic assessment at 47 months (range, 3 to 92 months) showed 33 patients with no or only trivial MR and 3 patients with grade I–II MR. The results of the echocardiographic study are summarized in Table 3. The left ventricular end-diastolic and end-systolic diameter decreased significantly after operation. The reduction in left atrium was substantial. There have been no thromboembolic events, no recurrent endocarditis, and no major hemorrhagic complications. Four patients have received permanent pacemakers. Thirty-three patients remain in New York Heart Association functional class I, whereas 3 are in class I–II. The completeness of follow-up during the closing interval (April 1998 to November 1998) was 100%. There has been no mortality up to this point. Reoperation at 1 and 5 years was not required in 94.6%. Seven patients who previously suffered from atrial fibrillation are now in sinus rhythm.


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  		Table 3. Results of Echocardiographic Study

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Myxomatous mitral annular calcification is a degenerative process, probably resulting from increasing stress on the aging mitral valve. The calcification primarily affects strongly the posterior annulus but may extend into the myocardium, chordae, and papillary muscles (Fig 1A). This is unlike the calcification in rheumatic valvular disease, which essentially involves the commissures and chordae, and in which the thickened leaflet tissue has a late extension to the annulus. Such annular bar calcification is a risk factor for death in mitral valve operations, because of AV rupture [5]. Subvalvular calcification involving the annulus requires removal that leaves the atrium, ventricle, and valve separated and in need of reconstitution. In such patients, most surgeons are discouraged from repair and favor valve replacement [5–8]. However, loss of annular–chordae–papillary continuity after valve replacement results in an inefficient globular geometry of the heart [4]. Preservation of the mitral valve mechanism can be expected to best preserve ventricular function [3, 4, 24, 25].

Contraindications and valve replacement
The proper selection of patients should diminish the prevalence of reoperation. Severely fibrotic and immobile leaflets, heavily deformed subvalvular apparatus, and active nonlocalized infection are considered contraindications to repair in general. Friability, heavy and generalized calcifications of the valve, or calcification involving nearly the entire annulus are features not suitable for repair.

Five patients were excluded from our study due to severe calcification of nearly the entire annulus in addition to complex valve pathology. Spiderlike severe rheumatic tissue stiffness of the anterior leaflet, massive destruction of struct chordae that normally constitute the cornerstone architectural function of the commissural leaflet closure, irregular and deficient attachment of anterior leaflet chordae system, or severe endocarditis with multiple areas of rupture and endocardial ulceration were found in these patients, which made valve replacement unavoidable. The major elements of the procedure included debridement of the calcium mass, reconstitution of the disassembled AV groove with straddling endoventricular autologous pericardial patch and valve replacement [18]. Mechanical St. Jude valves were implanted in 3 patients. To achieve more normal left ventricular function after valve replacement, polytetrafluoroethylene sutures were used as chordae tendineae to restore the integrity between the mechanical valve and papillary muscles and therefore, the left ventricular wall. The other 2 patients have received Baxter bioprosthesis (Baxter Healthcare Corp, Irvine, CA), implanted with retention of part of the valve leaflets.

Plastic repair
When good annulus and leaflet motion can be achieved in calcified mitral valves, calcium debridement allows successful repair and therefore, offers an advantage to valve replacement [8, 11, 18, 19]. In our patients, isolated mitral regurgitation in rheumatic mitral valve disease with development of commissural lesions and calcified masses ulcerating onto the atrial surface was associated with dilatation of the mitral valve annulus rather than severe fibrosis and shrinkage of both mitral leaflets. The calcification had reached the annulus at the base of the posterior leaflet and extended down the chordae to the papillary muscles. Calcium debridement of the affected commissure and annulus with use of rotation paracommissural sliding plasty (Fig 3), or repair variations with pericardial patch (Fig 1D) has been successfully performed. With freely mobile and fully competent leaflets after repair, it is important to recognize that presence of calcification in rheumatic carditis should not be the major impediment to preclude mitral valve reconstruction with application of newer techniques. Several excellent long-term results were obtained in this group of patients after mobilization of valvular and subvalvular tissue, which gave them new suppleness [19–21]. Application of pretreated autologous pericardium, with absence of antigenicity, in pericardial patch extended endocardial annuloplasty, which remains flexible at midterm follow-up, is a reliable technique to protect the left ventricle from rupture after en bloc calcium removal [10, 18]. The mitral annulus remains stable without evidence of early calcification or fatigue in our midterm observation. Sliding atrioplasty procedures provide uncomplicated practical feasibility to reconstruction, which contribute to avoiding systolic anterior motion after repair. Rotation paracommissural sliding plasty involves creating a new commissure by extended sliding plasty and rotating the posterior mitral leaflet. This produces a fully competent valve of adequate orifice by maximal use of the remaining leaflets and their chordal support, and preserving the 1:3 ratio between the width of the posterior and the anterior leaflets (Fig 3R). However, mitral valve reconstructive operation without annuloplasty entails a high incidence of early failures [14, 20, 21]. At present, concepts of valvuloplasty require a combination of annulus remodeling to relieve any tension on the reconstructed leaflets, as well as annular flexibility to preserve the physiologic valvular function, resulting in good short-term results [16, 17, 22, 23]. Thirty-one patients in our late series were treated with the flexible ring to restore the posterior annulus mobility after decalcification; there were no complications of ring dehiscence. Systolic anterior motion with left ventricular outflow tract obstruction has not occurred in these patients.

At present there is no ideal mitral valve substitute. Consequently, operative techniques aimed at conserving the patient’s native mitral valve and avoiding anticoagulation remains attractive. Carpentier [11], Duran [20], and Bernal [21] and their colleagues described the concept of surgical correction directed at repairing all affected components of the mitral valve, with encouraging achievement of good valve function at late follow-up. The impressive progress in surgical skill [10–15, 18, 20, 21] and medical management in the past decade is an undeniable contribution to our good results with almost negligible mortality and morbidity in these patients. This population represents our total experience of calcified mitral annulus repair including the learning curve. We believe that these results are reproducible and can be expected from other surgical groups, achieved with a constant learning process and changing of surgical attitude.

In our patients, valvuloplasty is a safe operation with a low incidence of reoperation. Freedom from reoperation at 1 and 5 years was 94.6%. No thromboembolic episodes were recorded. Calcium debridement was performed in these patients without any increase in the risk of perioperative mortality. The actuarial survival is 100%, and functional status has improved remarkably after valve repair. Our echocardiographic studies, with significant reduction in left ventricular end-diastolic and left atrium dimension, and continued valve competence demonstrate the efficacy of valvuloplasty using several different surgical techniques. Until now, 31% of patients have returned to permanent sinus rhythm. This result is promising and implies another definite advantage to improving patient care, in addition to freedom from many of the complications associated with valve replacement. At present, "echo-perfect repair" has an adequate long-term outcome [26]. Surgical correction of MR with contemporary repair of the annulus after calcium debridement is an extremely useful operative technique for patients with complex mitral valve disease, and should be encouraged and considered in all patients in which operation is contemplated. The complications attributable to annulus calcification associated with MR can be anticipated and avoided, or treated promptly when they occur. Our current follow-up agrees with studies by Grossi and associates [19] who reported that severe calcification does not affect long-term outcome of valvuloplasty. Valvuloplasty performed by surgeons proficient with this technique can offer outcome advantages suggesting that early operation is feasible before ventricular dysfunction occurs, and allows for new strategies in these patients [4, 24, 25].

In summary, the encouraging beneficial midterm results strongly suggest that annulus decalcification and valvuloplasty can be safely undertaken in patients who suffer from mitral valve insufficiency associated with extensive calcification of the mitral apparatus. This experience with calcium debridement allows durable and predictable repair of valves that otherwise need to be replaced. Further investigation will be necessary to determine long-term results. We suggest patients with severely calcified mitral apparatus should not be precluded from consideration of reconstruction.


   Acknowledgments
 
We are deeply grateful to Drs Delos M. Cosgrove, III, Carlos M.G. Duran, Tirone E. David, and Marko I. Turina, who are great teachers having taught us different reconstructive surgical techniques and methods to avoid complications for our patients.


   Footnotes
 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/. In addition, a video clip of this procedure can be viewed on the Internet at http://www.sts.org/section/atsvideo/


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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Accepted for publication December 16, 1999.




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