Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome

European Journal of Cardio-thoracic Surgery 32 (2007) 596—603 www.elsevier.com/locate/ejcts Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome Cosimo d’Alessandro, Nicola Vistarini, Stéphane Aubert, Frédérique Jault, Christophe Acar *, Alain Pavie, Iradj Gandjbakhch Received 1 March 2007; received in revised form 13 June 2007; accepted 15 June 2007; Available online 15 August 2007 Abstract Objective: The aim of this study was to determine the factors influencing the feasibility of valve repair and the surgical outcome in patients with mitral annulus calcification. Methods: In 124 patients with mitral annulus calcification undergoing surgery, two entities were distinguished: Barlow disease (myxomatous leaflets, n = 60) and fibroelastic deficiency (FED) (normal leaflets, n = 64). The calcification score was lower (1.9 vs 2.8); the annulus was more dilated (ring 35 vs 32 mm) and ruptured chordae were more frequent (77% vs 37%) in Barlow than in FED ( p < 0.001). The clinical profile was different: age (60  14 vs 73  8 years, p < 0.001), systemic hypertension (22% vs 70%, p < 0.001), chronic renal insufficiency (5% vs 22%, p < 0.01), cancer (7% vs 25%, p < 0.01). Multifocal atherosclerosis was less frequent in Barlow than in FED: carotid disease (17% vs 54%, p < 0.001), aortic atheroma (21% vs 51%, p < 0.001) and coronary disease (22% vs 56%, p < 0.01). Echocardiography showed two different patterns in Barlow and FED: aortic valve stenosis (1.7% vs 31%), left atrial diameter (54 vs 49 mm), left ventricular end-diastolic diameter (62 vs 54 mm), interventricular septal thickness (11 vs 13 mm), and systolic pulmonary pressure (40 vs 56 mmHg), respectively ( p < 0.001). Bacterial endocarditis was observed in 24 cases (19%). Results: The surgical technique was a valve repair in 68% and a replacement in 32%. The repair rate depended upon the extent of annulus calcifications ( p < 0.001) and the type of degenerative disease (95% vs 44% in Barlow and FED p < 0.001). In-hospital mortality was 14% (Barlow: 5% vs FED: 23%, p < 0.01). The mean follow-up was 50  41 months. Overall 5-year year survival was 76% (Barlow: 90% vs FED: 64%, p < 0.001) and survival free from cardiac event was 69% at 5 years (Barlow: 87% vs FED: 52%, p < 0.001). Five-year survival was higher following repair than replacement (84% vs 64% p < 0.001). Chronic renal insufficiency and bacterial endocarditis were two predictors of early and late death ( p < 0.01). Conclusions: The aetiopathogeny of the degenerative mitral disease responsible for annulus calcifications corresponded to distinct anatomical, clinical and echographic patterns. It was a main determinant of repair feasibility, early and late surgical outcome. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. Keywords: Mitral annulus calcification; Mitral valve repair; Mitral valve replacement 1. Introduction 2. Methods Mitral valve repair has emerged as the ideal treatment for degenerative mitral insufficiency and the possibilities of valve repair have reached 95% for this aetiology in experienced teams. Undoubtedly, calcifications of the mitral annulus represent the main anatomical obstacle to valve repair in this indication. The decalcification with sliding plasty technique described by Carpentier et al. [1] has considerably increased the possibilities of surgical reconstruction, but valve replacement still remains necessary in some cases. The aim of this study was to identify the anatomical, clinical and echographic factors influencing the feasibility of the repair and the determinants of the early and late surgical outcome in case of mitral annulus calcification. 2.1. Patient population * Corresponding author. Tel.: +33 142 16 56 85; fax: +33 142 16 56 78. E-mail address: (C. Acar). One hundred twenty-four patients with mitral annulus calcification underwent surgery between 1995 and 2005. Patients’ age was 66  13 years (23—88 years). Fifty-five patients (44%) were in functional class NYHA I or II and 69 patients (56%) were in functional class NYHA III or IV. The operation was performed in emergency in 11 cases (9%). Five patients had undergone a previous valve surgery (aortic valve replacement n = 4, failed attempt at mitral valve repair n = 1). ECG showed a sinus rhythm (n = 67, 54%), sinus rhythm with paroxysmal atrial fibrillation (n = 32, 26%) or permanent atrial fibrillation (n = 25, 20%). Eight patients (6%) were paced with a permanent stimulator. Marfan syndrome was present in four cases. Chronic renal insufficiency was noted in 17 cases (14%): creatinine level >200 mg/l (n = 9) or haemodialysis (n = 8). Systemic hypertension was observed in 58 1010-7940/$ — see front matter # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejcts.2007.06.044 Département de Chirurgie Cardiovasculaire, Institut de Cardiologie, Hôpital Pitié Salpétrière, 50-52 Bd Vincent Auriol, 75013 Paris, France C. d’Alessandro et al. / European Journal of Cardio-thoracic Surgery 32 (2007) 596—603 (n = 4). A large cavity containing caseous necrosis was found in three cases. 2.2. Surgical technique Mitral valve repair was performed in 85 cases (68%). In case of a calcification localised to one segment, it was either removed together with the prolapsed area or left in place when it involved a commissure (Fig. 1). When the calcium bar was extended to two segments or more of the mitral annulus, the Carpentier decalcification technique [1] was used (n = 34). It comprised a disinsertion of the posterior leaflet with en bloc removal of the calcium bar and posterior leaflet sliding plasty (Fig. 2). The other techniques of repair were: posterior leaflet quadrangular resection (n = 78), annulus plication (n = 54), chordae transposition on the anterior leaflet (n = 13), commissural closure (n = 9), pericardial patch (n = 3) or direct (n = 1) closure of a perforation. All caseous or abscessed collections were evacuated and the cavity was deterred and closed directly except in one case in which a pericardial patch was used. Prosthetic ring annuloplasty was accomplished in all cases with either a Carpentier physio (n = 24) or a Duran ring (n = 61). The mean intercommissural distance of the ring was 34.2  2.6 mm. Intraoperative echocardiography control of the repair was routinely performed. Mitral valve replacement was achieved in 39 cases (32%) with a bioprosthesis (n = 34) or a mechanical valve (n = 5). The technical details are described on Fig. 3. The mean diameter of the prostheses was 28.9  2.4 mm. The associated procedures included: aortic valve replacement in 23 cases (18%) (Bioprosthesis n = 20, mechanical n = 3), septal myectomy (n = 2), tricuspid valve annuloplasty (n = 3), pulmonary veins isolation (n = 2) and coronary artery grafting in 18 cases (14%). The average bypass time was 83 (...truncated)