“The stony heart”: perioperative management of severe mitral annular calcification and porcelain left atrium in a patient requiring prolonged cardiopulmonary bypass

Sangaraamunisen Ramachandran; Thomas Francis; Abdul M. B. Jasid

doi:10.18203/2349-2902.isj20260339

Authors

Sangaraamunisen Ramachandran Department of Cardiothoracic Surgery, Hospital Sultan Idris Shah, Selangor, Malaysia
Thomas Francis Department of Cardiothoracic Surgery, Hospital Sultan Idris Shah, Selangor, Malaysia
Abdul M. B. Jasid Department of Cardiothoracic Surgery, Hospital Sultan Idris Shah, Selangor, Malaysia

DOI:

https://doi.org/10.18203/2349-2902.isj20260339

Keywords:

Mitral annular calcification, Porcelain atrium, Mitral valve replacement, Paravalvular leak, Prolonged cardiopulmonary bypass

Abstract

Mitral annular calcification (MAC) presents a formidable challenge in cardiac surgery, often transforming routine valve replacement into a complex reconstruction. When combined with a "porcelain" left atrium, the risks of atrioventricular disruption and inability to expose the valve increase exponentially. Herein this case report presents the case of a 56-year-old female with rheumatic heart disease and a "porcelain" left atrium who underwent mitral valve replacement (MVR). Preoperative multidisciplinary discussion, including consultation with visiting US cardiothoracic faculty, established a consensus to "respect the calcium" rather than perform radical debridement, prioritizing atrioventricular integrity over annular geometry. The intraoperative course was complicated by a rigid, calcified annulus resulting in significant paravalvular leak (PVL). This necessitated two surgical revisions and a total cardiopulmonary bypass time of 367 minutes. Following a managed recovery strategy, the patient was extubated on postoperative day 2 and discharged home on day 7. Severe MAC with a porcelain atrium represents a "double jeopardy" scenario. Successful management requires a multidisciplinary "respect the calcium" strategy and the mandatory use of intraoperative transesophageal echocardiography (TOE). This case demonstrates that prolonged bypass time is a justifiable investment to ensure a competent valve and that aggressive ICU management can mitigate the physiological insult of extended surgery.

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References

Abramowitz Y, Jilaihawi H, Chakravarty T, Mack MJ, Makkar RR. Mitral Annulus Calcification. J Am Coll Cardiol. 2015;66(17):1934-41. DOI: https://doi.org/10.1016/j.jacc.2015.08.872

Guerrero M, Dvir D, Himbert D, Urena M, Eleid M, Wang DD, et al. Transcatheter Mitral Valve Replacement in Native Mitral Valve Disease With Severe Mitral Annular Calcification: Results From the First Multicenter Global Registry. JACC Cardiovasc Interv. 2016;9(13):1361-71. DOI: https://doi.org/10.1016/j.jcin.2016.04.022

Carpentier AF, Pellerin M, Fuzellier JF, Relland JY. Extensive calcification of the mitral valve annulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996;111(4):718-29. DOI: https://doi.org/10.1016/S0022-5223(96)70332-X

Feindel CM, Tufail Z, David TE, Ivanov J, Armstrong S. Mitral valve surgery in patients with extensive calcification of the mitral annulus. J Thorac Cardiovasc Surg. 2003;126(3):777-82. DOI: https://doi.org/10.1016/S0022-5223(03)00081-3

Saran N, Greason KL, Schaff HV, Cicek SM, Daly RC, Maltais S, et al. Does Mitral Valve Calcium in Patients Undergoing Mitral Valve Replacement Portend Worse Survival? Ann Thorac Surg. 2019;107(2):444-52. DOI: https://doi.org/10.1016/j.athoracsur.2018.07.098

Götz W, Limberg J. Surgical Treatment of Mitral Annular Calcification (MAC). Front Cardiovasc Med. 2022;9:852234.