225. Advanced Experience Allows Robotic Mitral Valve Repair in the Presence of Extensive Annular Calcification
Didier F. Loulmet, Neel K. Ranganath, Michael S. Koeckert, Siyamek Neragi-Miandoab, *Aubrey C. Galloway, *Eugene A. Grossi
NYU Langone Health, New York, NY
Invited Discussant: Stephanie L. Mick
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. It is a common contraindication to the robotic approach. We review the safety and efficacy of totally endoscopic robotic MV repair (TERMVR) in the presence of MAC, with an emphasis on pathology and repair techniques.
Methods: Between May 2011 and August 2017, the same two surgeon team attempted TERMVR (da VinciTM) in 64 MAC cases, accounting for 12.8% of our robotic MV experience during the same period. If MAC was associated with a totally calcified posterior leaflet (PL), patients were not considered for TERMVR. If MAC was associated with a pliable PL, operations were performed robotically, through ports, with retrograde perfusion, and endo-balloon aortic occlusion. When possible, MAC was excised as a mono-block using electrocautery; the PL was separated from MAC and spared; the AV groove was reconstructed; the PL was reattached to the neo-annulus; and annuloplasty completed the repair.
Results: Mean age was 64.2 years with 26 (41%) patients older than 70. There were 34 (53.1%) women. Eight (12.5%) patients had a BMI >30. Twelve (18.8%) patients were in NYHA class >2. Mean LVEF was 65%. MAC extension and repair technique are presented in the Table. Repair was converted to replacement in 2 (3.1%) patients. Eight (12.5%) patients required concomitant cryoablation, 5 (7.8%) hybrid PCI, and 2 (3.1%) tricuspid annuloplasty. Median aortic-occlusion and CPB times were 122.5 and 161 minutes respectively, excluding cases with concomitant tricuspid repair. Extubation in the operating room was obtained in 33 (52%) patients. Median length of stay was 4 days. Residual MV regurgitation on discharge TTE was none-to-mild in all patients. Two (3.1%) patients were readmitted within 30 days. Early (30-day) mortality was 3.1% (2/64).
Conclusions: MAC is present in a significant percentage of patients with MV regurgitation. Utilizing a variety of repair techniques, TERMVR can be performed safely and effectively in most MAC cases when the PL is not calcified.
Table. MAC incidence, extension, and repair techniques.
Extension to the PMs
MAC excision and AV groove repair
AV groove repair with a bovine patch
AV groove repair with mattresses on pledget
AV groove repair with annuloplasty sutures only
MAC left alone