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
Figure 1: Preoperative chest radiograph
Figure 2: 1st Preoperative echocardiography shows the mitral valve
Figure 4: 2nd Preoperative echocardiography shows the aortic valve
Operative Findings of Mitral Valve
Postop echocardiography of the mitral valve
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  to 98.3% at 8 years .
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 . 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 . 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 .
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 . Shomura et al.  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.
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