Cavitron ultrasonic surgical aspirator for mitral annular decalcification

Video Tutorial ◽

Cavitron Ultrasonic Surgical Aspirator ◽

Consensus Strategy ◽

Annular Calcification ◽

Ultrasonic Surgical Aspirator ◽

Patient Presentation ◽

Severe Calcification

Mitral valve surgery can be especially difficult in patients with mitral annular calcification. Not only is it associated with higher morbidity and mortality, but there is no consensus strategy for the treatment of mitral annular calcification, which may render some patients inoperable. We describe a case of severe mitral annular calcification successfully treated with the cavitron ultrasonic surgical aspirator. We demonstrate the proper technique for and the efficacy of using this instrument for decalcification of the mitral annulus. The video tutorial includes the patient presentation, preoperative and postoperative imaging, and the proper surgical technique for cavitron ultrasonic surgical aspirator-assisted mitral annular decalcification. With the proper technique, the cavitron ultrasonic surgical aspirator may mitigate the risk of surgical complications associated with severe calcification of the mitral annulus.

Immediate outcomes of treatment of severe mitral annular calcification

Russian Journal of Transplantology and Artificial Organs ◽

10.15825/1995-1191-2021-2-52-59 ◽

2021 ◽

Vol 23 (2) ◽

pp. 52-59

Author(s):

R. M. Muratov ◽

M. N. Sorcomov ◽

A. S. Sachkov ◽

S. I. Babenko ◽

A. M. Sleptsova ◽

...

Keyword(s):

Mitral Valve ◽

Annulus Fibrosus ◽

Posterior Wall ◽

Mitral Annulus ◽

Mitral Valve Surgery ◽

Left Ventricular ◽

Calcium Deposition ◽

Valve Function ◽

Mitral annular calcification (MAC) is a chronic degenerative process involving the fibrous part of the mitral complex, characterized by calcium deposition and loss of valve function. MAC prevalence is 8–10%, but despite this, the clinical significance of MAC is underestimated. Currently, there are reports that complete decalcification leads to improved long-term outcomes in patients with severe MAC. An analysis of the immediate outcomes of mitral valve surgery in patients with severely calcified mitral annulus with decalcification was performed. The calcified annulus fibrosus underwent complete decalcification in all cases. Calcium deposits were removed in a single block, in 6 cases it was reconstructed with a xeno-pericardial patch; in 2 cases the annulus fibrosus was sutured. There were 2 cases of in-hospital mortality, caused by acute heart failure on day 8 in 1 patient and pulmonary embolism on day 30 after operation in the second patient. There were no complications associated with coronary artery injury and left ventricular posterior wall rupture. Experience in the treatment of severe mitral valve calcification with extensive annulus fibrosus decalcification and subsequent reconstruction is possible and gives satisfactory results.

Tumours of the heart: Diagnostic dilemma

Srpski arhiv za celokupno lekarstvo ◽

10.2298/sarh1006343r ◽

2010 ◽

Vol 138 (5-6) ◽

pp. 343-346

Author(s):

Ljiljana Rankovic ◽

Milorad Borzanovic ◽

Milan Vukovic ◽

Aleksandar Radovic ◽

Sinisa Gradinac

Keyword(s):

Mitral Annulus ◽

Mitral Valve Insufficiency ◽

Tumor Formation ◽

Elderly Persons ◽

Diagnostic Dilemma ◽

Valve Insufficiency ◽

Degenerative Disorder ◽

Mitral Apparatus ◽

Introduction Mitral annular calcification is a degenerative process of the fibrosus support structure of the mitral apparatus, usually spreading over the posterior mitral leaflet. Case Outline A 66-year-old woman with shortness of breath and palpitations was referred to our institution. Echocardiography showed a round, echo-dense mass, resembling a tumour, in the posterior mitral annulus, with the third degree mitral regurgitation. Based on the findings, surgical treatment was suggested involving removal of the tumour and correction of mitral valve insufficiency. During surgery the posterior annulus was incised, whitish caseous material was aspirated and the developed cavity was closed. A bioprosthetic valve was placed in the mitral position. The aspirated material was sent to bacteriological and histological analysis. Eight days after surgery control echocardiography and CT scan of the heart showed absence of the mass. Pathohistological finding was nonspecific. Bacteriology showed Staphylococus spp. Thirteen days after surgery the patient was discharged in stabile condition. Conclusion Mitral annular calcification is a common degenerative disorder particularly in elderly persons. As the diagnosis very often remains unrecognised imitating a tumor formation, precise diagnostics is necessary before possible surgery. .

Risk of Cerebral Embolization with Caseous Calcification of the Mitral Annulus: Review Article

The Open Cardiovascular Medicine Journal ◽

10.2174/1874192401610010221 ◽

2016 ◽

Vol 10 (1) ◽

pp. 221-232 ◽

Cited By ~ 7

Author(s):

Charles A. Dietl ◽

Christopher M. Hawthorn ◽

Veena Raizada

Keyword(s):

Surgical Resection ◽

Mitral Annulus ◽

Cardioembolic Stroke ◽

Asymptomatic Patients ◽

Cerebrovascular Events ◽

Increased Risk ◽

Cerebral Embolization ◽

History Of ◽

Background: Caseous calcification of the mitral annulus (CCMA) is believed to have a benign prognosis. Several authors have recommended conservative management in asymptomatic patients. However, the prevalence of cerebrovascular events (CVE) in patients with CCMA has never been evaluated before. The aims of this study are to investigate whether patients with CCMA are at increased risk of cerebral embolization, and to determine whether elective surgical resection of CCMA should be considered to prevent a cardioembolic stroke. Methods: A comprehensive literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, and Google Scholar using the following search queries: caseous calcification of the mitral annulus, intracardiac pseudotumor, mitral annular calcification, and cardioembolic stroke. Results: From our initial search that yielded 1,502 articles, we identified a total of 130 patients with CCMA reported in 86 publications. Literature review revealed that the prevalence of CVE associated with CCMA is 19.2% (25 of 130) which is significantly higher than the prevalence of CVE reported with mitral annular calcification (MAC), 11.8% (214 of 1818) (range 4.8% to 24.1%) (P = 0.01796) (odds ratio = 1.78; 0.95 confidence interval = 1.1278 – 2.8239). Only four of 25 (16.0%) patients with CCMA who suffered a CVE had history of atrial fibrillation (AF). Conclusion: Based on our review, it would be reasonable to consider elective surgical resection of CCMA in asymptomatic patients who are good surgical candidates, because patients with CCMA may be at increased risk of embolic strokes, which are unrelated to AF.

Mitral annular calcification: Can CMR be useful in identifying caseous necrosis?

Interventional Medicine and Applied Science ◽

10.1556/1646.10.2018.47 ◽

2019 ◽

Vol 11 (1) ◽

pp. 71-73

Author(s):

Matteo Gravina ◽

Grazia Casavecchia ◽

Vincenzo Manuppelli ◽

Antonio Totaro ◽

Luca Macarini ◽

...

Keyword(s):

Mitral Annulus ◽

Caseous Necrosis ◽

Intracardiac Mass ◽

Fibrous Cap ◽

Posterior Mitral Leaflet ◽

Extensive Calcification ◽

Mitral Annulus Calcification ◽

Definition Of ◽

Mitral annular calcification (MAC) can resemble an intracardiac mass and it is defined as a chronic degeneration of the mitral annulus. Often reported is caseous mitral annulus calcification (CMAC), a periannular, extensive calcification resembling a tumor. We report the case of a 68-year-old woman who had been hospitalized for palpitations and dyspnea. The transthoracic and transesophageal echocardiography revealed a non-homogeneous, slightly mobile, round mass, attached to the ventricular side of posterior mitral leaflet, with central echo-lucent area and without acoustic shadowing. Therefore, a cardiac magnetic resonance (CMR) was performed; delayed enhancement sequences showed a non-enhanced central core surrounded by a hyperenhanced rim (fibrous cap). To confirm the diagnosis, a multidetector computed tomography (MDCT) was performed; the MDCT showed a hyperdense mass with a hypodense center and a calcified peripheral rim. The central content had heterogeneous fluid density without significant contrast enhancement. The MDCT findings were considered highly suggestive of CMAC. CMR may be useful for the identification and definition of pericardial and myocardial masses and CMAC.

Abstract 17000: Quantifying Mitral Annular Calcification Using Echocardiography: Comparison to MAC Calcium Score From Gated Computed Tomography

Circulation ◽

10.1161/circ.142.suppl_3.17000 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

William Harvey ◽

Sheldon Litwin

Keyword(s):

Computed Tomography ◽

Mitral Valve ◽

Left Atrial ◽

Left Atrial Volume ◽

Calcium Score ◽

Mitral Annulus ◽

Atrial Volume ◽

Close Proximity ◽

Introduction: Mitral Annular Calcification (MAC) is present in 25-40% of people ≥ 60 years old and has associations with atrial fibrillation, stroke, endocarditis, mitral regurgitation, and mitral stenosis. MAC poses major challenges to surgical or transcatheter mitral valve interventions. Current echocardiographic methods for assessing MAC are limited. Goals: To assess transthoracic echocardiographic (TTE) approaches for quantifying MAC severity compared to a gold standard of MAC calcium score by gated computed tomography (CT). Methods: 75 patients undergoing evaluation for TAVR had TTE and CT in close proximity. MAC area and circumference were measured in parasternal long-axis (PLAX), parasternal short-axis (PSAX), and apical 2, 3, and 4-chamber views on TTE. Mitral valve gradients and left atrial volume were recorded. The curvilinear length of MAC in the PSAX view on TTE and cardiac CT were also measured. Associations between various TTE measures and MAC calcium score were assessed using linear regression. Results: Median age was 75.3, 50.4% female, 85.3% Caucasian. MAC area and circumference in PSAX on TTE showed moderate correlations (R 2 =0.32-0.37) with MAC calcium score. Curvilinear MAC length measures on SAX TTE and CT had improved correlation with MAC score (R 2 =0.41 & 0.78, Figure). Combined circumference of MAC from PLAX+PSAX had the strongest association (R 2 = 0.48). Interobserver variability on CT and TTE had coefficients of variation ranging 17-37%. Left atrial volume and mitral valve gradients had weak associations with MAC severity (R 2 =0.03-0.12). Tertiles of MAC calcium scores were 2650, 5150 and 7750. Conclusions: MAC length in the PSAX view showed the strongest association with MAC severity. Dedicated PSAX views of the mitral annulus may improve the ability to reproducibly grade MAC severity by echo.

Abstract 11452: Are Patients With Caseous Calcification of the Mitral Annulus But Without Atrial Fibrillation at Increased Risk of Cerebral Embolization?

Circulation ◽

10.1161/circ.130.suppl_2.11452 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Charles A Dietl ◽

Christopher M Hawthorn ◽

Veena Raizada

Keyword(s):

Atrial Fibrillation ◽

Mitral Annulus ◽

Benign Condition ◽

Increased Risk ◽

Cerebral Embolization ◽

Mitral Annulus Calcification ◽

Unusual Variant ◽

History Of ◽

Background: Caseous calcification of the mitral annulus (CCMA) is very uncommon, and is frequently misdiagnosed as an intracardiac tumor, thrombus, abscess, or simply as mitral annular calcification (MAC). These masses are generally believed to have a benign prognosis. The aims of this study are to increase the awareness of this unusual variant of MAC, and to determine whether patients with CCMA are at increased risk of cerebral embolization in patients with or without atrial fibrillation (AF). Methods: A comprehensive literature search was done to determine whether patients with CCMA are at increased risk of cerebral embolization, using the following search modules: caseous calcification of the mitral annulus, mitral annular calcification, cerebral embolization with mitral annulus calcification, risk of stroke with mitral annular calcification. Results: Among the 496 articles listed in PubMed.gov, ScienceDirect.com, and Google Scholar, a total of 129 patients with CCMA were identified in 85 publications, and 31 articles were reviewed to evaluate the incidence of stroke in 1800 patients with MAC. Literature review revealed that the incidence of cerebrovascular events (CVE) associated with CCMA is 18.6% (24 of 129) which is even higher than the risk of embolic CVE reported in patients with MAC, 11.6% (209 of 1800) (range 4.8% to 24.1%). Only 2 of 24 patients (8.3%) with CCMA who suffered a CVE had history of AF, whereas the majority (22 of 24, or 91.7%) of CCMA patients with a CVE did not have AF. Conclusions: Despite the fact that several reports suggest that CCMA is a benign condition, CCMA may be potentially serious, because of the increased risk of cerebral embolization, even in patients without atrial fibrillation.

Mitral Valve Surgery in Patients With Extensive Mitral Annular Calcification: Outcomes and Long-Term Follow-Up

Heart Lung and Circulation ◽

10.1016/j.hlc.2019.02.069 ◽

2019 ◽

Vol 28 ◽

pp. S89

Author(s):

M. Gardner ◽

K. Hossack ◽

I. Smith

Keyword(s):

Mitral Valve ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Long Term Follow Up ◽

Impact of mitral annular calcification associated mitral stenosis on clinical outcomes in patients undergoing transcatheter aortic valve implantation

European Heart Journal ◽

10.1093/ehjci/ehaa946.1966 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Mesnier ◽

M Urena ◽

C Nguyen ◽

J.L Carrasco ◽

Z Terzian ◽

...

Keyword(s):

Aortic Valve ◽

Ct Scan ◽

Clinical Outcomes ◽

Mitral Stenosis ◽

Pacemaker Implantation ◽

Mitral Annulus ◽

Common Finding ◽

Valve Implantation ◽

Abstract Introduction Mitral annular calcification (MAC) is a common finding in patient undergoing transaortic valve implantation (TAVI) and can cause significant mitral stenosis (MS). Purpose To assess the impact of MAC associated with significant MS (MAC-MS) on clinical outcomes following TAVR. Methods Consecutive patients undergoing TAVI in our institution between January 2008 and May 2018, were evaluated. All echocardiogram exams before intervention were analysed to identify the presence of MAC and MAC was confirmed on computed tomography (CT) scans. Patients were included in the MAC group if there was any calcification on the mitral annulus on CT scan. Severe MAC was considered as calcification of the mitral annulus involving over 50% of the circumference. Patients with a mitral mechanical valve or bioprosthesis and without CT scan available to confirm MAC were excluded (n=62). MAC-MS was defined as the association of MAC and a mean transmitral gradient over 5 mmHg. Results Among 1177 consecutive finally included patients, 504 (42.8%) had MAC and 85 had a MAC-MS (7.2%, 16.9% among the MAC population). Compared to MAC without MS (MAC non-MS group) and non-MAC patients, patients with MAC-MS were more frequently women (p<0.0001), had a greater BMI (p=0.002), more previous pacemaker implantation (p=0.035), smaller indexed aortic valve area and left ventricular end systolic diameter (p=0.019 and p=0.038). At 30-days after TAVR, there were no differences in stroke, major vascular complication and pacemaker implantation between groups. However, MAC-MS patients had higher rates of tamponade [Odd Ratio adjusted 3.12, 95% confidence interval (CI) 1.08–9.07, p=0.036] and mortality [Adjusted hazard Ratio (HRa) 2.83, 95% CI 1.39–5.76, p<0.005] after adjustment on baseline characteristics. At 1 year, patients with MAC-MS had a higher risk of death [19 (22.1%) vs. 142 (13%); HRa 1.83, 95% CI 1.14–3.03, p=0.01] compared to MAC non-MS and non-MAC patients. Severe MAC was not a predictor of 1 year mortality. Conclusions Mitral stenosis due to mitral annular calcification is infrequent in patient undergoing TAVI but is associated with higher early and mid-term mortality. Funding Acknowledgement Type of funding source: None