Annals of cardiothoracic surgery最新文献

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.

Background: Annular calcification [mitral annular calcification (MAC)] may complicate mitral valve (MV) surgery, and long‑term outcome data are limited.

Methods: We reviewed adult patients undergoing MV surgery at our Clinic between January 2000 and December 2024. MAC was identified on preoperative imaging, and operative strategy prioritized repair when feasible and employed conservative debridement when necessary. Patients with MAC were matched 1:1 with patients without MAC using a propensity score.

Results: Among 11,350 MV operations with or without concomitant procedures, 1,603 patients (14.1%) had MAC, the median age was 72.6 years [interquartile range (IQR), 65.3-78.6 years], 54.8% were female. In the MAC cohort, 21% of patients had a prior sternotomy. Concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) were performed in 32% and 24% of cases, respectively. Compared with propensity-matched controls, MAC patients did not exhibit significantly prolonged cardiopulmonary bypass times (115 vs. 112 minutes, P=0.485) or aortic cross-clamp durations (86 vs. 81 minutes, P=0.273). The 30-day hospital readmission rate was significantly higher among MAC patients (15.9% vs. 9.9%, P<0.001). Although 30-day mortality was elevated in the MAC group (5.8% vs. 4.2%), the difference was not statistically significant (P=0.171). In a subgroup analysis of matched groups undergoing primary isolated MV surgery, early mortality was 2.7% in patients with MAC and 0.5% in patients without MAC (P=0.111). Long-term, 10-year survival was significantly lower in MAC patients (43.6%) compared to matched controls (49.6%, P<0.001).

Conclusions: In this large single-center series, patients with MAC often had associated aortic valve and coronary artery disease, and 21% of them were undergoing a second procedure. Compared to matched patients without MAC, long-term survival was reduced in patients with MAC. This experience highlights the importance of accurate preoperative assessment and tailored surgical strategy to achieve acceptable outcomes of MV surgery in the presence of MAC.

Mitral annular calcification (MAC) is a chronic process that presents a complex clinical pathology. In the setting of a growing elderly population, the incidence of MAC has been increasing and it is often associated with other degenerative conditions most importantly atherosclerosis. While its clinical impact has previously been underappreciated, more recent evidence suggests that MAC has significant implications on cardiovascular and cerebrovascular morbidity as well as mortality. Commonly MAC is associated with mitral valve disease, which can require non-medical treatment in the form of conventional mitral valve surgery, transcatheter mitral valve replacement or a hybrid approach. The presence of MAC has important implications on both the interventional methods and subsequently on clinical outcomes. This review focuses on the diagnosis, clinical implications, and implications on mitral valve surgery and/or transcatheter interventions of MAC.

Transcatheter mitral valve intervention (TMVI) has emerged as a potential alternative to surgery for patients with mitral annular calcification (MAC)-associated mitral valve disease, a population often deemed high-risk due to clinical and anatomic complexities. However, MAC also presents significant challenges to TMVI itself. In transcatheter edge-to-edge repair (TEER), procedural success may be limited by fibrotic and short leaflets, reduced mitral valve area, and subvalvular calcium protrusion. Transcatheter mitral valve replacement (TMVR) poses further anatomical hurdles, including a small, eccentric, or non-conforming annuli; insufficient MAC to ensure anchoring; narrow aortomitral angle; septal hypertrophy; elongated anterior mitral leaflet predisposing to left ventricular outflow tract (LVOT) obstruction; and heterogeneous MAC morphology leading to paravalvular leak or suboptimal fixation. Mechanical injury to adjacent structures such as the circumflex artery and atrioventricular groove is also a concern. Balloon-expandable valves, used off-label for TMVR, may be delivered via transapical, transfemoral, transseptal, or hybrid transatrial approaches. While early data show high mortality for valve-in-MAC (ViMAC) procedures, a shift toward transfemoral transseptal access has improved outcomes. The hybrid transatrial approach offers advantages including resection of the anterior leaflet, septal myectomy, and reinforcement of the valve skirt with Teflon felt. Among dedicated self-expanding TMVR systems, only Tendyne has both CE mark and US Food and Drug Administration (FDA) approval and is delivered transapically. New transfemoral transseptal systems-such as Intrepid, AltaValve, and Cephea-are under active investigation. Techniques like LAMPOON (Laceration of the Anterior Mitral leaflet to Prevent Outflow ObstructioN) and BATMAN (Balloon-Assisted Translocation of the Mitral Anterior Leaflet) have been developed to mitigate the risk of fatal LVOT obstruction. Despite progress, mid-term mortality after ViMAC TMVR remains high. Continued innovations in technique, device design, and patient selection are critical to establishing TMVI as a viable treatment for MAC-associated mitral valve disease.