Posterior dehiscence of prosthetic mitral prosthesis after intra-atrial implantation.
Central Message.
During mitral valve replacement, the prosthesis must be anchored to the true annulus to avoid the risk of early dehiscence.
The mitral valve annulus is a discontinuous fibrous arc connected anteriorly to the cardiac fibrous skeleton at the right and left trigones,1 which provides an appropriate anchor for durable mitral valve replacement (MVR). Certain pathologies of the mitral annulus pose a challenge to standard MVR, such as radiation-induced heart disease, mitral annular calcification (MAC), invasive endocarditis, or multiple reoperations. In these circumstances, adequate debridement of the annulus and additional support are required for stable implantation of the mitral prosthesis. In this article, we present a case series of failed MVR procedures performed by anchoring the posterior aspect of the prosthesis into the left atrium wall, rather than the true annulus. We caution against the use of this technique and describe technical pitfalls highlighted by 3 cases that required reoperation for valve dehiscence. Institutional review board approval was not required, and informed consent was waived.
Intra-atrial Implantation of the Mitral Prosthesis
In 1988, Gandjbakhch and colleagues2 published a report of intra-atrial MVR for a case of extensive annular destruction secondary to endocarditis. The technique was further highlighted by Nataf and colleagues,3 who reported outcomes from a larger patient series. This paper described using a Dacron collar to enlarge the valve circumference, with standard horizontal mattress sutures passed through the sewing ring of the prosthesis and a second running suture through the outer collar for reinforcement. Of the 36 patients in this series (58% for extensive MAC and 42% for endocarditis), operative mortality was 36%, including 1 intraoperative death secondary to catastrophic left atrial tearing. Of the surviving cohort, 4 patients required reoperation as a result of paravalvular leak (PVL). In addition, the duration of follow-up was not reported; however, there was one late reoperation attributable to thrombosis on the ventricular side of the mitral prosthesis. Although these rates of early failure are considered high by contemporary standards, the authors advocated for this technique as a bailout strategy because of its simplicity compared with aggressive annular debridement and reconstruction.
Since this initial series, there have been several additional reports in the literature replicating this technique.4, 5, 6, 7, 8 Adequate follow-up is lacking, with another small series by a different group reporting postoperative echocardiographic data in only 2 patients up to 70 days.9 Furthermore, there is considerable variability in the technique; some groups have continued the use of a Dacron collar around the valve as initially described, whereas others have advocated for a more aggressive, double-layered suture line without collar reinforcement.8 The authors of 1 report describing MVR for severe MAC even advocate for leaving the in situ native valve completely intact below the intra-atrial implanted prosthesis.5 Although specific execution varies, all implementations of this technique rely on sutures embedded in thin, left atrial tissue to endure sustained ventricular pressure.
Case 1
This clinical case is summarized in Video 1. A 62-year-old female patient presented 1 year after aortic and MVR with dyspnea on exertion. A transesophageal echocardiogram showed dehiscence of the posterolateral portion of the mitral prosthesis, causing torrential mitral regurgitation, as well as vegetations suggestive of endocarditis. Notably, the surgeon in the previous surgery documentation indicated that exposure of the mitral valve through the interatrial groove was difficult, along with calcification of the posterior mitral annulus. The patient underwent redo double-valve replacement; given the possibility of colonization of the aortic prosthesis, and to optimize visualization of the mitral valve, the aortic prosthesis was replaced. The mitral valve was approached via a transseptal approach, and a large paravalvular defect was found posteriorly (Figure 1). After the mitral prosthesis was explanted, it was evident that the entire posterior sewing ring was implanted above the anulus in the left atrium (Figure 2). After adequate debridement, the new valve sutures were placed circumferentially around the native anulus, incorporating the fibrous annular tissue to seat an adequate size prosthesis (MITRIS #29 mm). Because of a concern for patient-prosthesis mismatch, a posterior aortic annular enlargement was performed before implanting the aortic prosthesis (INSPIRIS #25 mm). Postoperative echocardiogram showed a mitral prosthesis seated at the annulus with no PVL (Figure 3). These findings persisted at a routine 6-month interval echocardiogram.
Figure 1.
Posterior dehiscence of prosthetic mitral prosthesis after intra-atrial implantation.
Figure 2.
Intra-atrial implantation of mitral prosthesis in false versus true annulus.
Figure 3.
Annular implantation of mitral prosthesis. The red line indicates the plane of false annulus.
Case 2
A 60-year-old female patient with morbid obesity presented at an outside hospital in decompensated right heart failure 2 years after MVR. She experienced no symptomatic improvement after her operation, in which the surgeon implanted the mitral prosthesis (size #29 mm) in the left atrium above the MAC. A follow-up echocardiogram at 3 months showed development of severe PVL (Video 2). Transcatheter closure of the PVL was unsuccessful. Right heart catheterization showed severe postcapillary pulmonary hypertension with preserved cardiac index. She was considered high risk and was transferred to our center for further management.
During the reoperation, the mitral prosthesis was exposed through a transseptal approach and revealed a wide dehiscence along the posterior sewing ring. After the mitral prosthesis was explanted, the posterior MAC was carefully debrided, and a bovine pericardial patch was used to reconstruct the annulus. A MITRIS #33 mm prosthesis was implanted, incorporating the valve sutures in the pericardial patch and the posterior MAC capsule. Postoperative echocardiogram showed a well-seated mitral prosthesis with no PVL (Video 3). Echocardiogram at 1-year follow-up showed normal biventricular function, mild pulmonary hypertension, and a well-functioning mitral prosthesis.
Case 3
A 65-year-old male patient presented with a complex surgical history, including MVR 12 years before presentation for endocarditis, complicated by early dysfunction requiring re-replacement within 6 months. Two years later, recurrent endocarditis prompted a third MVR. He presented to our center with congestive heart failure symptoms. Echocardiogram showed severe mitral PVL (Video 4). During his fourth redo MVR, the mitral valve was exposed via a transseptal approach. The posterior circumference of the prosthesis was dehisced, and after explant, it was noted that it was implanted entirely in the left atrium above the true annulus. With inadequate debridement during the previous reoperations, a fibrotic ring (false annulus) developed above the level of the true annulus and was mistakenly used to anchor the new prosthesis in the left atrial wall (Figure 4). After adequate debridement, valve sutures were placed around the true annulus with incorporation of the posterior leaflet, and a new prosthesis (Biocor #33 mm) was implanted (Figure 5). Postoperative echocardiogram showed a well-seated mitral prosthesis with no regurgitation (Video 5). The follow-up echocardiogram at 2 months showed similar stable results.
Figure 4.
Transseptal view after previous mitral valve explant. The dashed line refers to false annulus while new prosthesis sutures are incorporating native annulus.
Figure 5.
New mitral prosthesis well seated within the true annulus.
Comment
The mitral annulus is composed of a discontinuous fibrous band that extends between the fibrous trigones of the cardiac skeleton framework and is supported by the subvalvular apparatus, which provides an appropriate anchor for the mitral prosthesis against high pressure in the left ventricle. In contrast, the left atrial wall contains a thin muscular layer and is devoid of fibrous tissue that could serve as an adequate anchor for the mitral prosthesis to withstand the left ventricular pressure in systole. MAC represents a surgical challenge, with increased risk for PVL, atrioventricular groove disruption, and operative mortality.10, 11, 12 Nearly 30 years ago, Carpentier13 published exceptional results with radical, en bloc resection of MAC with complete annular reconstruction. The approach was not widely adopted because of the technical difficulty and the fact that not all patients with MAC were suitable for this approach. We have previously described our stepwise approach for MVR in cases of MAC, with a less-radical approach that may enhance reproducibility.14, 15, 16 Our approach includes debridement of bulky MAC with preservation of the posterior MAC capsule, which provides a stable anchor to the mitral prosthesis. In our experience, this approach allows proper seating of an adequate-sized prosthesis at the annular level and reduces the risk of atrioventricular laceration. We support the annulus with a strip of felt or pericardial patch (without tension) on the basis of the size of the defect and the quality of the tissues. We use the native mitral leaflets to support the annulus when feasible.17 Other groups have published different techniques to resect or circumvent the MAC with good results.10 Stefano and colleagues18 described a unique method of creating a “neo-annulus” by plicating the mitral leaflets to the left atrial wall, allowing for intra-annular anchoring of the prosthesis. Ishida and colleagues19 proposed a “Dumpling technique,” which combines a traditional limited debridement and reconstruction with a pericardial collar reinforcement. Importantly, these techniques innovate new ways to anchor the prosthesis to the annulus rather than bypassing it.
There has been increased interest in transcatheter mitral valve replacement (TMVR) in the setting of MAC, because it negates the need for aggressive debridement and its associated risks. The first series—deploying predominantly transseptal or transapical and relying exclusively on radial forces for securement—experienced 28% technical failures with 30% operative mortality.20 Development of a “hybrid approach” improved technical success by using annular securement sutures, similar to a traditional valve replacement. Subsequent reports of TMVR through a hybrid approach show better outcomes, although risks of residual PVL and left ventricular outflow tract obstruction remain high.21,22 Currently, available devices for TMVR are Tendyne, Intrepid, and SAPIEN valves (the latter used off-label for the hybrid transatrial approach).23 In our practice, the severity of MAC is not a contraindication for surgery. Indications for TMVR could be patients with prohibitive surgical risk and favorable anatomy for percutaneous options.
Even in the absence of MAC, mitral anatomy can be obfuscated after multiple reoperations. Fibrous rinds that form around the sewing ring can create a “shelf” within the left atrium that can mimic the true anulus and mislead the surgeon, as illustrated by our third case. In these cases, adequate debridement of pannus and surgical material and understanding of the postdebridement anatomy are of paramount importance to anchor the new prosthesis to the true annulus and subvalvular apparatus. Defects in the annulus after debridement should be augmented with preserved leaflets or pericardial patch.
Suspicion of previous intra-atrial implantation can be raised on preoperative transesophageal echocardiography and confirmed by identification of atrial pseudoaneurysm (area lost the smooth appearing atrial wall) above the true annulus, which can be identified by following the attachment of the posterior leaflet at the atrioventricular junction (Figure E1). Our approach for reoperative MVR in cases with anticipated difficult exposure (eg, high body mass index, significant adhesions in the left chest) is a transseptal approach, which can be extended to the dome of the left atrium to optimize exposure of the mitral valve. We dissect out the apex of the heart for better visualization of the anterior mitral valve annulus.
Figure E1.
Diagram showing the development of posterior left atrium pseudoaneurysm in cases of intra-atrial implantation of mitral prosthesis. LV, Left ventricle.
Conclusions
In cases with challenging mitral annulus pathologies such as MAC, invasive endocarditis, or multiple reoperations, intra-atrial implantation of the mitral prosthesis during MVR can be tempting. However, this technique, although easier for the surgeon, can be costly for the patient and carries the risk of early failure. Respecting the fundamentals of the cardiac anatomy for secure implantation of the prosthesis in the true annulus remains the cornerstone of durable MVR.
Conflict of Interest Statement
H.E. receives speaking honorarium from LifeNet Health, Artivion, and Edwards Lifesciences. A.M.G. serves as a consultant to Edwards Lifesciences, Medtronic, Abbott, ClearFlow, AtriCure, CorCym, Artivion, Johnson & Johnson, and Baxter. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Supplementary Data
Case summary of valve dehiscence after intra-atrial implantation of mitral prosthesis. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Case 2: preoperative transesophageal echocardiogram demonstrating severe paravalvular leak. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Case 2: postoperative transesophageal echocardiogram demonstrating no residual paravalvular leak. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Case 3: preoperative transesophageal echocardiogram showing prosthetic mitral dehiscence with valve rocking. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Case 4: postoperative trans-esophageal echocardiogram showing appropriate valve seating. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Appendix E1
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Associated Data
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Supplementary Materials
Case summary of valve dehiscence after intra-atrial implantation of mitral prosthesis. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Case 2: preoperative transesophageal echocardiogram demonstrating severe paravalvular leak. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Case 2: postoperative transesophageal echocardiogram demonstrating no residual paravalvular leak. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Case 3: preoperative transesophageal echocardiogram showing prosthetic mitral dehiscence with valve rocking. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.
Case 4: postoperative trans-esophageal echocardiogram showing appropriate valve seating. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00366-9/fulltext.