Repeated mitral valve replacement in a patient with extensive annular calcification
© Kitamura et al; licensee BioMed Central Ltd. 2011
Received: 31 May 2011
Accepted: 14 November 2011
Published: 14 November 2011
Mitral valve replacement in the presence of severe annular calcification is a technical challenge.
A 47-year-old lady who had undergone mitral and aortic valve replacement for rheumatic disease 27 years before presented with dyspnea. At reoperation, extensive mitral annular calcification was hindering the disc motion of the Starr-Edwards mitral prosthesis. The old prosthesis was removed and a St Jude Medical mechanical valve was implanted after thorough annular debridement. Postoperatively the patient developed paravalvular leak and hemolytic anemia, subsequently undergoing reoperation three days later. The mitral valve was replaced with an Edwards MIRA valve, with a bulkier sewing cuff, after more aggressive annular debridement. Although initially there was no paravalvular leak, it recurred five days later. The patient also developed a small cerebral hemorrhage. As the paravalvular leak and hemolytic anemia gradually worsened, the patient underwent reoperation 14 days later. A Carpentier-Edwards bioprosthetic valve with equine pericardial patches, one to cover the debrided calcified annulus, another as a collar around the prosthesis, was used to eliminate paravalvular leak. At 7 years postoperatively the patient is doing well without any evidence of paravalvular leak or structural valve deterioration.
Mitral valve replacement using a bioprosthesis with equine pericardial patches was useful to overcome recurrent paravalvular leak due to severe mitral annular calcification.
KeywordsMitral valve replacement Annular calcification Surgical procedures
Severe annular calcification of the mitral valve is a major challenge to cardiac surgeons. Thorough debridement is mandatory to obtain satisfactory fitting of the prosthetic valve to the annulus. However, too much aggressive debridement can lead to atrioventricular groove perforation. Herein we present a case of prosthetic valve disorder of the mitral valve with extended annular calcification which developed 27 years after the initial surgery, requiring redo valve replacement three times to manage a paravalvular leak.
Severe annular calcification is an independent risk factor for mitral valve operations  and can make the procedure technically challenging . When the calcification process deeply involves the myocardium, sutures cannot be placed through the affected tissue. Additionally, the rough surface of the annulus can cause paravalvular leak even if a prosthesis with an expanded, heavy sewing cuff is used. On the other hand, excessive debridement may lead to atrioventricular groove perforation or injury to the circumflex artery. When there is severe annular calcification, aggressive annular debridement together with covering the annulus with a pericardial patch may be indicated to prevent paravalvular leak [3, 4] because the patch simply obliterates the paravalvular blood flow and because it provides better fitting between the prosthesis and the rugged annular surface. In the present case, the left ventricular pressure was elevated due to the aortic prosthetic valve gradient. In addition, the annular calcification was so extensive and the debrided surface was so rough that paravalvular leak recurred even after the second operation. At the third operation, the risk of paravalvular leak and subsequent hemolysis was very high. Therefore, a bioprosthesis was used despite the patient's relatively young age with the expectation that the risk of hemolysis caused by the hammering effect of the mechanical valve  would be reduced. Placement of an equine pericardial patch eliminated the paravalvular leak. This was probably because of the "caulking" effect achieved by the patch tissue placed between the sewing cuff and the annulus, rather than by obliteration of the paravalvular blood flow by the collar sewn onto the left atrium.
Mitral valve replacement with a bioprosthesis, together with the use of equine pericardial patch, could eliminate recurring paravalvular leak caused by severe mitral annular calcification extending to the left ventricle.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-chief of this journal.
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