A case of supra-annular mitral valve replacement using chimney technique for severe mitral stenosis with extensive mitra
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CASE REPORT
A case of supra‑annular mitral valve replacement using chimney technique for severe mitral stenosis with extensive mitral annular calcification Seimei Go1 · Tomokuni Furukawa1 · Kazunori Yamada1 · Toshifumi Hiraoka1 · Shingo Mochizuki1 Received: 4 September 2019 / Accepted: 15 November 2019 © The Japanese Association for Thoracic Surgery 2019
Abstract When patients with extensive mitral annular calcification undergo mitral valve replacement, excessive debridement of calcification may result in fatal complications and may protract operation time. We report a case of supra-annular MVR using “the chimney technique” on a high-risk patient for severe mitral stenosis with extensive mitral annular calcification. This technique is usually used in small infants whose mitral annulus is smaller than the smallest available prosthetic valve. We apply this technique to minimize the debridement of calcification and shorten the operation time. The operation was successfully completed, and the postoperative course has been uneventful. This technique was safely and easily performed, and eliminated the need for aggressive debridement of the calcification. We believe this technique may be a good choice for high-risk patients with mitral annular calcification. Keywords Mitral annular calcification · Mitral valve replacement · Composite graft
Introduction
Case report
Mitral annular calcification (MAC) is a chronic degenerative noninflammatory condition characterized by calcification of the fibrous support surrounding the mitral valve. It is often observed in patients undergoing long-term hemodialysis. Extensive calcification of the mitral annulus may present a formidable surgical challenge during mitral valve surgery. The patient is at risk from potentially fatal complications such as intractable hemorrhage, atrioventricular disruption, and ventricular rupture. Some surgeons [1] conduct mitral valve surgery with complete annular decalcification and reconstruction with a pericardial patch. It is, however, sometimes difficult to completely decalcify the annulus and acquire a sufficient diameter to implant a suitable mechanical valve. We therefore used the chimney technique to implant a suitable mechanical valve in a small annulus narrowed by calcification.
A 70-year-old female was referred to our institution because of exertional dyspnea. She had been receiving hemodialysis for diabetic nephropathy for 11 years. Her past medical history was significant for hypertension and for arteriosclerosis obliterans after endovascular treatment. Furthermore, she had undergone aortic valve replacement (mechanical valve) 7 years prior. On admission, her blood pressure was 118/70 mmHg, her pulse was 100/min, and she had an O 2 saturation of 88% on room air. The X-ray photogram indicated strong pulmonary congestion. The transthoracic echocardiogram revealed a severe mitral stenosis and severe calcification in the posterior leaflet and annulus. The mean pressure gradient of the mitral valve was 16.3 mmHg, and the mean mitral valve a
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