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First Reported Series Of Endoscopic Transposition Of The Anterior Mitral Leaflet As A Patch For Posterior Annular Mac Debridement
Mario Castillo-Sang, Mickey Ising, George Christensen;
St. Elizabeth Healthcare, Edgewood, KY, USA
BACKGROUND: The management of deeply debrided posterior mitral annular calcification or annular abscess is challenging and a carries significant mortality risk. There are 4 published experiences of the anterior mitral leaflet as a posterior annular patch. We report three consecutive endoscopic MVR cases with anterior leaflet transposition to patch the posterior annulus and illustrate the technique with operative images and video.
METHODS: Three patients undergoing endoscopic MVR ages 64, 72, and 60 years-old with severe posterior MAC were treated with transposition of the anterior leaflet to patch the debrided posterior mitral annulus. Patients 1 and 2 presented with endocarditis and abscess complicating posterior MAC. Patient 1 had two areas of infected MAC, patient 2 one area. Patient 3 had posterior MAC with caseous calcification. All three patients underwent successful endoscopic MVR, patients 1 and 2 with tissue valves (sizes 33 mm and 31mm respectively), and mechanical debridement using rongeurs plus tricuspid repairs. Patient 3 had a mechanical MVR (size 25/27 mm) with ultrasonic decalcification plus left atrial ablation and appendage closure. After antegrade cardioplegic arrests the mitral valves were exposed via the interatrial groove and the posterior annular debridement was carried out prior to cutting the base of the anterior leaflet. This allowed preservation of the anterior leaflet for patching. Patient 1 required two separate areas of posterior patching, patient 2 required a central posterior area, and patient 3 one large posterior area. The patches were sutured with 3-0 polypropylene in a mattress fashion. The posterior annular sutures were placed through the patch, and the valves were implanted using titanium fasteners.
RESULTS: All patients survived without stroke, reoperation, or major complications, and the replaced valves had low mean transmitral gradients without paravalvular leaks. Lengths of stay were 10, 7, and 4 days respectively. All three patients were thriving at 1 year, 8 months, and 3 months respectively with normal ventricular function.
CONCLUSIONS:Complex posterior mitral annular debridement for MAC or endocarditis can be successfully managed endoscopically with posterior transposition of the anterior mitral leaflet as a patch. This approach preserves the ventricular-annular continuity and avoids the use of foreign material.
Figure 1:
Tissue valve implanted with Polyester sutures applied through the anterior leaflet patch. Intraoperative image of the anterior leaflet patch.
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