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Posterior Mitral Leaflet Augmentation and Artificial Chordae Reconstruction for a Hemodialysis Patient with Mitral Regurgitation and Mitral Annulus Calcification

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Posterior Mitral Leaflet Augmentation and Artificial Chordae Reconstruction for a Hemodialysis Patient with Mitral Regurgitation  and Mitral Annulus Calcification

Yusuke Sakurai, MD, Koji Hattori, MD, Akihiro Kobayashi, MD, Tsutomu Yanagisawa, MD, Mika Noda, MD, Kentaro Amano, MD, Yoshiro Higuchi, MD, Masato Tochii, MD, Michiko Ishida, MD, Hiroshi Ishikawa, MD, Yoshiyuki Takami, MD, Yasushi Takagi, MD

Department of Cardiovascular Surgery, Fujita Health University


•Surgical procedures for combined valvular disease in high-risk patients is challenging.
•Mitral valve surgery in patients who have severe mitral valve regurgitation (MR) with mitral annulus calcification (MAC) can be difficult.
•We treated an elderly hemodialysis patient who had severe MR with MAC as well as severe aortic valve stenosis.
•She underwent aortic valve replacement and mitral valve surgery. We employed mitral valve plasty (MVP) with patch augmentation of the posterior mitral leaflet (PML), thereby avoiding MAC decalcification to minimize the invasiveness of the surgery.

Case Presentation

•77-year-old woman
•150 cm, 45 kg, BSA 1.40 m2
•18-year history of hemodialysis
•STS score: 9.8%
•ECG: sinus rhythm
•Clinical history
•Dyspnea on effort
•Repeated hospitalization due to congestive heart failure

Figure 1: Preoperative chest radiograph

Figure 2: 1st Preoperative echocardiography shows the mitral valve

•Severe MR jet to posterior wall
•No mitral leaflet prolapse
•Arrow indicates shortened PML (P2)

Figure 3:

•Arrows indicate  MAC on posterior mitral annulus
•No calcification on the PML

Figure 4: 2nd Preoperative echocardiography shows the aortic valve

•Severe aortic stenosis
•Peak velocity: 4.76 m/sec
•Systolic peak/mean pressure gradient: 91/53 mmHg
•Aortic valve orifice area: 0.88 cm2

Surgical Procedure

1.Via median sternotomy with cardiopulmonary bypass and cardioplegic arrest
2.Mitral valve plasty
a.Right side approach to left atrium
b. Patch augmentation of PML
c.Cut the thick, shortened chordae that restricted the P2 leaflet
d.Artificial chordal reconstruction for P2 and A2
e.No ring annuloplasty
3.Aortic valve replacement
a. Bioprosthetic valve replacement (Magna EASE TFX 19 mm; Edwards Lifesciences)
b.Supra-annular position

Operative Findings of Mitral Valve

Figure 5:

•The PML was free from calcification except for the P2 tip. Although P2 was thick and had shrunk to about 5 mm in height, the PML was pliable and had flexibility.
•The thick, shortened chordae was attached to P2.

Figure 6:

•The 20-mm incision of the PML, staying 2 mm away from the posterior annulus.
•Patch augmentation with autologous pericardium (ellipse-shaped: 25×10 mm) treated with 0.6% glutaraldehyde solution for 8 min.

Figure 7:

•A first water test revealed MR.
•Cause of remaining MR was the P2 leaflet restricted by the thick, shortened chordae. Therefore, we cut the chordae.
•Artificial chordal reconstruction with the loop technique was performed for P2 and A2 to adjust the height of the coaptation line.
•A final water test revealed no MR.

Postop echocardiography of the mitral valve

Figure 8:

•Echocardiography shows no MR.
•Diastolic mean pressure gradient: 4 mmHg


•Surgical techniques for MR with MAC are still controversial.
•Many procedures have been reported.

1. Mitral valve surgery with complete MAC decalcification  

  Advantages: Both mitral valve replacement (MVR) and MVP are possible. Long-term results of this   surgical procedure have been reported. The freedom from reoperation reported in the literature varies        from 90.5% at 5 years [1] to 98.3% at 8 years [2].

  Disadvantages: MAC decalcification may result in fatal complications, such as ventricular rupture and   circumflex coronary artery damage. Operative mortality ranges from 6.2% to 9.3% [3-6]. This   surgical procedure requires reconstruction of the mitral annulus and more surgical time than other   procedures.

 2. MVR without MAC decalcification: It requires placement at the mitral leaflets or the left atrium wall. An alternative is to use a collar-reinforced prosthetic valve. 

  Advantages: These surgical procedures are performed to avoid the complications associated with    MAC decalcification. Their mortality rate is thought to be better than that of surgery with MAC   decalcification. Okita et al. reported no mortality for six cases using a collar-reinforced prosthetic   valve [7]. However, none of the studies of MVR without MAC decalcification enrolled a large   number of cases.

  Disadvantages: Remaining bulky calcium may interfere with proper insertion of a prosthesis and   increase the risk of paravalvular leakage and valve dehiscence [8]. D’Alessandro et al. reported   that only 1 in 39 patients who underwent MVR without MAC decalcification required reoperation   because of valve dehiscence at 22 months [6].

3. MVP without MAC decalcification (our procedure): Leaflet augmentation with pericardial patch and chordal reconstruction.

  Advantages: The surgical risk of MVP without MAC decalcification is lower than that of other   procedures with MAC decalcification. The operative mortality was 0-3.7% [9,10].   Pericardium is used extensively in cardiac surgery because it is readily available, easy to handle,   and pliable. Indeed, evidence supports the long-term durability of an autologous pericardial patch   for the mitral leaflet [11]. Shomura et al. [12] reported that only 3 in 139 patients who underwent  mitral valve repair with autologous pericardium required mitral reoperation because of   deterioration of the pericardial patch at 10 years.   Disadvantages: This procedure could be performed in limited patients: those in whom the mitral   leaflet is pliable without extension of the MAC to the leaflet.

•In our case, PML was fortunately free from calcification and pliable. To reduce operative risk and operative time, we considered that severe MR would be regulated by using posterior leaflet augmentation with a  pericardial patch, avoiding MAC decalcification.
•We did not perform ring annuloplasty because the posterior mitral annulus was fixed with MAC. There was no cardiac event or in-hospital mortality during her postoperative course.
•Careful follow-up for the pericardial patch is needed because she is being treated with hemodialysis.


•Posterior mitral leaflet augmentation for poor-risk MR patients with MAC is a feasible option for surgery concomitant with aortic bioprosthetic valve replacement.


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2.   Uchimuro et al. Mitral valve surgery in patients with severe mitral annular calcification. Ann Thorac Surg 2015

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      Cardiovasc Surg 2003;126:777-82

4.Papadopoulos et al. Midterm survival after decalcification of the mitral annulus. Ann Thorac Surg 2009;87:1143-7

5.   Grossi et al. Severe Calcification does not affect long-term outcome of mitral valve repair. Ann Thorac    

       Surg 1994;58:685-8

6.    D’Alessandro et al. Mitral annulus calcification: determinants of repair feasibility, early and late surgical

       outcome. Eur J Cardiothorac Surg 2007;32:596-603

7.Okita et al. Mitral valve replacement with a collar-reinforced prosthetic valve for disrupted mitral annulus. Ann   

       Thorac Surg 1995;59:187-9

8.    Kurazumi et al. Mitral-valve replacement for a severely calcified mitral annulus: a simple and novel technique.    

       Eur J Cardiothorac Surg 2011;39:407-9

9.    Maisano F. Midterm results of edge-to-edge mitral valve repair without annuloplasty. J Thorac Cardiovasc

       Surg 2003;126:1987-97

10.  Chan et al. Impact of mitral annular calcification on early and late outcomes following mitral valve repair of    

       myxomatous degeneration. Interactive Cardiovasc and Thorac Surg 2013:120-126

11.  Scrofani et al. Mitral valve remodeling: long-term results with posterior pericardial annuloplasty. Ann  

       Thorac Surg 1996;61:895-9

12.  Shomura et al. LaterResults of mitral valve repair with glutaraldehyde-treated autologous pericardium. 

       Ann Thorac Surg 2013;95:2000-6

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