International Society For Minimally Invasive Cardiothoracic Surgery

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Robotic Mitral Annular Calcification Excision And Patch Repair Of Atrioventricular Groove
Michael S. Koeckert, MD, Neel K. Ranganath, MD, Hamza S. Sadhra, Mark V. Galstyan, Robert G. Nampiaparampil, MD, Didier F. Loulmet, MD, Aubrey C. Galloway, MD, Eugene A. Grossi, MD.
NYU Langone Health, New York, NY, USA.

OBJECTIVE: Mitral annular calcification (MAC) is underdiagnosed in mitral valve (MV) regurgitation patients. After excision, it may require reconstruction of the atrioventricular (AV) groove and decreases the probability of MV repair. Thus, MAC is a common contraindication to the robotic approach. We demonstrate a totally endoscopic robotic-assisted MV repair in the setting of severe MAC, including excision of annular calcification and AV groove patch reconstruction.
METHODS: A fifty-year-old man with Barlow’s disease and severe mitral regurgitation due to bileaflet prolapse presents for totally endoscopic robotic repair. His ejection fraction was 65% and other valves were structurally normal. Preoperative imaging revealed severe MAC particularly involving the anterior commissure between the hinge of P1 and the anterior papillary muscle. Cardiopulmonary bypass was initiated followed by left atriotomy and suture closure of the left atrial appendage. The mitral valve lesion was analyzed with a water test, which demonstrated bileaflet prolapse particularly involving P1 and P3. We began the repair by detaching the hinge of P1, followed by excision of a large area of annular calcification. This left a trench in the AV groove which was repaired with a bovine pericardial patch. The hinge of P1 was reattached to the upper edge of the patch with a running back-and-forth suture. MV repair was completed in standard fashion with band annuloplasty and triangular resection of P3. Initial water test revealed a leak between P2 and P3 with bulging of P3, which was subsequently repaired by partial resection of P3.
RESULTS: Final leak test was favorable and the patient was weaned from cardiopulmonary bypass with only trace residual mitral regurgitation. The patient was discharged home on post-operative day 7 without complication.
CONCLUSIONS: In the absence of a calcified posterior leaflet, MAC should not be considered a contraindication to the robotic approach to MV repair. Large defects to the AV groove can be repaired using a bovine pericardial patch technique.

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