Utility of the Ultrasonic Aspirator for Mitral Annular De-Calcification During Mitral Valve Repair

In patients undergoing mitral valve repair, the presence of severe mitral annular calcification can present technical issues. This video reports using the ultrasonic aspirator device (CUSA® Clarity, Integra LifeSciences; SONOPET® Ultrasonic Aspirator, Stryker Inc) during mitral repair to resect annular calcium in a safe and effective manner.

A 78-year-old woman presented with Class IV heart failure from severe mitral regurgitation in the setting of generalized bileaflet prolapse. She also had severe annular calcification. She was a very active 78-year-old and worked daily in her garden. She had good family support. The echo showed a multi-scalloped mitral valve with mild prolapse of both leaflets. The calcium was evident at the posterior annulus, and the central mitral leak was severe. After cardiotomy, the valve had generalized leaflet prolapse, a central coaptation gap, and impressive annular calcification. The calcium bar limited mobility of the annulus and atrial wall and was progressively removed using the ultrasonic aspirator without damaging surrounding structures. After resection, the posterior mitral annulus and atrial wall were quite mobile and capable of being sutured forward to the annuloplasty ring. A 30 mm Carpentier ring was sutured circumferentially to the annulus, using horizontal mattress sutures with supra-annular pledgets, and incorporating the ring in the annular suture line. A 2-0 Gore-Tex artificial chord was placed from the posterior papillary muscle to the prolapsing posterior leaflet (1). Chordal length was adjusted as the last step, and after an anterior leaflet chord and cleft closures, a completely competent valve was obtained with good leaflet mobility. At present, the patient is 12 years postoperative and is asymptomatic at age 90 years. Her activity level is normal, and her quality of life is excellent. The patient provided informed consent for publication of her clinical data and video images. Numerous approaches have been devised recently for managing mitral annular calcification. In application of these techniques, it is important to not forget the numerous advantages of mitral repair, and to recognize that the ultrasonic aspirator can assist in achieving good reparative outcomes, as illustrated by this patient.

Reference

Rankin JS, MD, Orozco RE, Rodgers TL, Alfery DD, Glower DD. “Adjustable” artificial chordal replacement for repair of mitral valve prolapse. Ann Thorac Surg. 2006;81:1526–1528.