Annals of cardiothoracic surgery最新文献

Background: Mitral annular calcification (MAC) is a degenerative calcific pathology of the mitral valve (MV) associated with MV dysfunction and poor patient outcomes. The pathophysiologic complexity of MAC presents unique challenges for surgical management. In this systematic review, we summarize the heterogenous approaches to MV surgery for MAC and assess early and late outcomes of each approach.

Methods: A systematic literature search was performed in the PubMed, EMBASE, and Web of Science databases. Three reviewers independently selected relevant studies through a sequential three-step review process. Based on included descriptions of intraoperative methods, each study was categorized as either a "MAC Respect" or "MAC Resect" intervention. Quantitative data were collected, aggregated across all studies, and analyzed by surgical approach.

Results: Our initial search yielded 635 unique studies, of which 19 studies met inclusion criteria for quantitative data extraction. Based on the operative approach, two cohorts of "MAC Respect" (N=550) and "MAC Resect" (N=487) were created. Baseline characteristics were similar; the median patient age and proportion of female patients were 71.5 years and 66.4% in the "Respect" group and 70.3 years and 54.9% in the "Resect" group, respectively. A median of 26.9% of patients in the "Resect" group and 12.5% in the "Resect" group were classified as New York Heart Association (NYHA) class III or IV. "Respect" studies had a median cardiopulmonary bypass time of 156 minutes, while "Resect" studies had a median time of 181.5 minutes. The median intensive care unit stay was two days for the "Respect" group and 3.5 days for the "Resect" group. Ranges of complication rates largely overlapped between groups. Thirty-day, one-year, and long-term mortality rates were 0-25%, 0-44%, and 0-27% in the "Respect" group and 0-14%, 0-18%, and 0-50% in the "Resect" group.

Conclusions: Surgical intervention remains the gold-standard for management of MAC-related MV dysfunction; however, there is no standardized consensus for the optimal surgical approach. This systematic review evaluates the advantages, disadvantages, and outcomes of several approaches to MAC surgical intervention. Our findings underscore the heterogeneous presentation of MAC and the associated complications to avoid in order to improve patient outcomes.

Background: Mitral annular calcification (MAC) is a chronic and degenerative process, affecting the mitral valve annulus. MAC complicates the decision over the appropriate surgical approach to mitral valve disease. Distorted valvular anatomy increases surgical risk and therefore requires careful patient selection. Here, we report our single-center experience performing mitral valve surgery in the setting of MAC over a 10-year period.

Methods: This is a 10-year retrospective analysis of 172 patients with MAC. Sixty-seven patients underwent MAC severity scoring using a 10-point system based on computed tomography (CT). The primary outcome was 30-day mortality, readmission, reoperation, stroke, prolonged ventilation, renal failure and deep sternal infection. Secondary analyses stratified MAC by underlying mitral disease type as well as evaluated outcomes by CT severity score. Patients without MAC undergoing mitral valve replacement surgery during the same time period served as controls.

Results: The 30-day mortality was significantly higher in MAC patients compared with non-MAC (9.9% vs. 4.2%, P<0.001), as were rates of stroke (4.7% vs. 1.6%, P=0.036), prolonged ventilation (33.1% vs. 21.1%, P<0.001), and renal failure (8.7% vs. 4.3%, P=0.008). Resource utilization was also greater, with longer intensive care unit (ICU) hours {118 [interquartile range (IQR), 58.2-254] vs. 72.3 (IQR, 41.0-141.5) hours, P<0.001}, postoperative length of stay [10 (IQR, 7-22) vs. 8 (IQR, 6-13) days, P<0.001], and total hospitalization [12 (IQR, 8-28) vs. 10 (IQR, 6-17) days, P=0.001].

Conclusions: MAC complicates mitral valve surgery, with significant differences seen in survival stroke, renal failure, prolonged ventilatory support, and ICU and hospital length of stay. Careful evaluation of surgical risk and patient selection is warranted in patients with MAC.

Mitral annular calcification (MAC) remains a challenging pathology in the context of mitral valve disease. It is associated with known cardiovascular risk factors, as well as a variety of chronic inflammatory, infective, or connective tissue diseases. Surgically, patients are at specific operative risk for atrioventricular dehiscence or rupture and/or injury to the circumflex artery. To mitigate these risks, a broad portfolio of surgical options exists to safely anchor annular sutures. This can be performed after the calcium bar has been removed and the posterior annulus reconstructed with a patch, or even when the calcium bar is left in place. Knowledge of these techniques will help surgeons manage MAC and implant a properly sized valve. Even in the presence of severe MAC with additional involvement of the mitral valve leaflets, transatrial transcatheter heart valve (THV) implantation may be a viable option. An individualized decision-making process to determine the applicable technique should be used for patients with MAC, leading to adequate treatment for this high-risk patient group.

Mitral annular calcification (MAC) is a heterogeneous condition that can complicate mitral valve (MV) repair and replacement operations. Surgery in the context of MAC varies considerably. Relatively simple repairs or replacements can be performed in several patients without the need to remove the calcium bar. However, extensive annular debridement, reconstruction of the atrioventricular junction, reconstruction of the intervalvular fibrous body, and mitral and aortic valve replacement may be necessary in some instances. Outcomes of these patients are directly related to the avoidance of technical problems amid a variety of potential anatomic challenges and pitfalls. Careful preoperative assessment, patient selection, detailed preoperative planning, and intraoperative judgment are required to optimize the chance of a successful outcome. Here we describe our approach to the MV patients with MAC, including preoperative planning, intraoperative technical tips and tricks, as well as a discussion of outcomes and remaining questions in this challenging population. This review only includes patients with MAC and MV dysfunction. It excludes those with associated aortic valve disease. The article contains a lecture on MV surgery in patients with MAC. We also highlight emerging experimental approaches, including hybrid and percutaneous techniques.

Background: Mitral annular calcification (MAC) poses technical and clinical challenges in patients undergoing mitral valve intervention. Patients with severe MAC were excluded from major previous randomized controlled trials evaluating mitral therapies. Consequently, outcomes following mitral transcatheter edge-to-edge repair (M-TEER) in this population remain controversial.

Methods: MEDLINE and EMBASE were searched through June 2025 to identify studies reporting outcomes after M-TEER in patients with MAC. This systematic review assessed the difference in MAC grading and M-TEER eligibility across studies. The definition of procedural success was documented to highlight inconsistencies. The primary endpoint was all-cause mortality during follow-up. Secondary endpoints included procedural success, heart failure rehospitalization, mitral valve reintervention, residual mitral regurgitation (MR), and mean mitral gradient.

Results: Six studies met inclusion criteria, including 2,808 patients undergoing M-TEER, of whom 363 (12.9%) had moderate-to-severe MAC. Most studies defined procedural success as MR reduction to grade ≤2, though only one incorporated a mean transmitral gradient <5 mmHg. MR reduction to ≤2 rates were comparable between patients with none-mild MAC and moderate-severe MAC. However, device success (MR reduction ≤2 and mean gradient <5 mmHg) was significantly lower in MAC patients (56.1% versus 81.3%). Post-procedural mitral valve gradient >5 mmHg occurred in 18.5-48.3% of MAC cases. Two studies reported increased all-cause mortality in patients with moderate-severe MAC during follow-up, with a mean follow-up of 20.4 months. Residual MR and reintervention rates were generally similar between groups, though mitral valve gradients tended to be higher in MAC patients.

Conclusions: M-TEER is feasible in well-selected patients with moderate-to-severe MAC; however, elevated post-procedural gradients remain a concern and may impact long-term outcomes. The absence of standardized eligibility criteria for M-TEER and consistent MAC quantification limits optimal patient selection. Comparative studies with surgical repair/replacement and transcatheter mitral valve replacement are critically needed to define optimal therapy.

Background: Mitral annular calcification (MAC) increases the complexity and risk of mitral valve surgery, often limiting repair feasibility. This study evaluates the early outcomes of ultrasonic emulsification and aspiration using a novel device to facilitate mitral valve repair.

Methods: We conducted a prospective, single-centre, single-surgeon series of 27 consecutive patients with moderate-to-severe MAC and degenerative mitral regurgitation (MR) undergoing Sonopet-assisted decalcification between June 2023 and July 2025. Procedures were performed via median sternotomy or endoscopic mini-thoracotomy. Ultrasonic aspiration was used to remove and sculpt MAC, enabling annular remodelling and secure repair. The primary outcome was repair success and residual regurgitation; secondary outcomes included mortality and perioperative complications.

Results: Mitral repair was successfully performed in 26 patients (96.3%), with one conversion to replacement. There were no in-hospital deaths, strokes, atrioventricular (AV) groove disruptions, or reoperations. At discharge, 96.3% had none or mild residual MR; one patient (3.7%) had moderate MR. Mean coaptation length was 10.3±3.2 mm. Postoperative complications included new-onset atrial fibrillation in five patients (18.5%) and permanent pacemaker implantation in two (7.4%). Sternotomy approach was used in 63% and endoscopic mini-thoracotomy in 37%. Mean cardiopulmonary bypass (CPB) and cross-clamp times were 159.6±46.8 and 116.9±46.5 min, respectively. Most mitral repairs addressed isolated posterior leaflet prolapse (66.7%) or bileaflet prolapse (22.2%). Primary repair strategies included leaflet resection (51.9%), isolated neochords (25.9%), or resection with neochords (22.2%). MAC decalcification was primarily performed in the posterior annulus.

Conclusions: Ultrasonic emulsification is a safe, effective adjunct for mitral valve repair in moderate-to-severe MAC, enabling precise decalcification and high repair rates with minimal complications. This approach may expand repair candidacy and merits further comparative studies with long-term follow-up.