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Institution: Royal North Shore Hospital - NSW, Australia
Purpose: Mitral Annular Calcification (MAC) remains a challenging anatomical and hazardous barrier in mitral valve surgery with increased periprocedural morbidity and mortality. It is a degenerative process that commonly affects elderly patients with myxomatous disease and favours the posterior annulus. While several techniques exist to circumvent this issue- including complete MAC resection or placing the valve at an angle in the atrium- they are complex and technically difficult with risks including atrioventricular disruption, circumflex artery injury, paravalvular regurgitation, valve dehiscence, and thromboembolism.
Methodology: We describe our experience in 30 patients who have undergone our original simplified technique. The technique involves leaving the MAC untouched, plicating the posterior leaflet up to the MAC and inserting the valve at the usual annular level while covering the calcification with a pericardial collar secured to the valve prosthesis that is then sutured to the atrium several centimetres from the prosthesis sewing ring. This prevents paravalvular regurgitation caused by small tears where the posterior leaflet was plicated.
Results: Thirty patients underwent this reproducible pericardial collar technique between 2003- 2024. There were two early deaths- one due to MRSA prosthetic endocarditis resulting in multiorgan failure, and another due to pre-existing liver failure. There were no paravalvular leaks demonstrated on intraoperative TOE and follow up TTE. There were no long-term complications or re-operations related to the technique. Importantly, there were no complications including stroke, atrioventricular disruption and circumflex injury.
Conclusion: This is a simplified, safe, and reproducible technique to deal with MAC that can be performed by all cardiac surgeons and be part of their mitral armamentarium.
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Authors
Dr Lucy Manuel - , Dr Philippa Bowers - , Dr Manu Mathur -