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Objective: Patients with severe calcification of the mitral annulus and severe mitral valve regurgitation, requiring mitral valve surgery, are at increased risk of operative morbidity and mortality. In this high-risk population, placement of an intra-atrial mitral valve prosthesis via a minimally invasive approach reduces operative times and surgical risks associated with conventional valve surgery. We report such a case.
Methods: A 74-year old female, with severe mitral annular calcification and severe mitral regurgitation, underwent minimally invasive intra-atrial placement of a mitral valve prosthesis via a right mini-thoracotomy by placing an 8 mm Dacron graft circumferentially sutured around the sewing cuff. Pledgeted sutures were placed circumferentially in the atrial wall above the mitral annulus and through the newly constructed sewing cuff, and the valve and sewing cuff were then seated in a supraannular position onto the atrial wall. Intra-operative and post-operative echocardiograms were performed to evaluate the adequacy of the prosthesis placement and assess for the presence of mitral regurgitation.
Results: The EuroSCORE risk calculation was 13.6, and the patient was in New York Heart Association functional class IV pre-operatively. Prior surgical history included aortic valve and ascending aorta replacement. A 25mm Medtronic Hancock II porcine mitral valve prosthesis was placed successfully, and there was no paravalvular leak observed post-operatively. The cardiopulmonary bypass time was 193 + 35 minutes. Moderate-to-deep hypothermia (24-26º C) and fibrillatory arrest were utilized. No mitral regurgitation was noted on post-operative transesophageal echocardiogram. The patient did well post-operatively with complete symptom resolution, and was discharged home on post-operative day six.
Conclusions: In patients requiring mitral valve replacement in which severe annular calcification prohibits standard valve surgery, intra-atrial placement of a mitral valve prosthesis via a minimally invasive approach is a feasible option.