Repeated mitral valve replacement in a patient with extensive annular calcification

Abstract

BackgroundMitral valve replacement in the presence of severe annular calcification is a technical challenge.Case reportA 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.ConclusionMitral valve replacement using a bioprosthesis with equine pericardial patches was useful to overcome recurrent paravalvular leak due to severe mitral annular calcification.

Paraprosthetic leak closure 28 years after mitral caged-ball Starr-Edwards implantation

“…However, in many studies, a Starr-Edwards valve was found to be functioning properly many years after implantation [1]. Valve replacement many years after implantation is often difficult because of extensive calcification of the mitral annulus and is associated with increased mortality [4]. In our case, the primary indication for operation was severe, symptomatic aortic stenosis.…”

On-pump fibrillating heart mitral valve replacement with the SAPIEN XT transcatheter heart valve

“…Standard mitral replacement can be difficult in the presence of heavy calcifications and can lead to severe complications. Additionally, the concomitant presence of previously implanted transcatheter aortic valves (in particular the self-expandable stent-valves) can limit the access site, the decalcification and the placement of a standard prosthesis [1][2][3][4][5]. In this scenario, hybrid techniques may help in finding safer, faster and easier way to treat complex valve diseases.…”

“…Mitral valve replacement with biological prosthesis is a valid treatment for elderly patients with non-repairable mitral disease [1][2][3]. However, mitral stenosis sometimes represents a challenging procedure, requiring valve replacement and extensive decalcification of the annulus, with risk of ventricular damage and bleeding [4]. Thus, new, minimally invasive, transcatheter or hybrid techniques for mitral replacement could represent a further step in the treatment of selected high-risk patients.…”

Surgical outcomes of mitral valve replacement with concomitant mitral annular reconstruction

“…Reconstruction of the mitral annulus is commonly performed in adults and children using autologous pericardium or glutaraldehyde‐fixed bovine pericardium . Some reports have described reconstruction using Dacron graft or equine pericardium …”