We have all encountered cases of severe MAC. Some have calcium which can be penetrated with a needle and the solution is simple.  Others may require extensive decalcification which may require a pericardial patch to reinforce the annulus. This can be quite a undertaking with a potential fatal outcome if one is not comfortable with the technique.

I have performed 6-7 cases utilizing a supra-annular MVR technique by suturing a 8mm dacron graft to the sewing cuff of a 25 mm bioprosthetic valve. Thereafter, multiple pledgeted mattress sutures are placed on the left atrial wall.  These are then placed through the dacron graft and tied over another pledget. The new valve usually sits approximately 1.5 cm above the native annulus.  The case that you see was performed yesterday.  I did have to reinforce the dacron graft with a running 4-0 prolene due to a minor leak.  I think that in the future I will try using Tevdek sutures which may provide a more secure knot.

This is definitely an simpler solution to a potentially difficult and fatal problem (AV disruption).  Approaching this via a minimally invasive approach also allows easier visualization and definition of the left atrial wall for suture placement.  Another point which can decrease operative time is to have the valve and dacron graft sewn prior to instituting CPB.

 It is usually a 25mm valve and the posts/struts of the valve usually sit on the calcified leaflets or just into the existing orifice.  I try to resect as much of the leaflets as possible to allow as large an orifice as possible.

(Sorry for the way the pictures look, but I am still trying to figure out how to align them and the captions properly.  It’s more difficult to do that, than to do this operation. If you click onto the pictures individually, they are very clear.)

Sever MAC, mini thoracotomy visualization (redo)

Anterior leaflet resected, posterior leaflet densely calcified

25mm valve, 8mm dacron graft, 5-0 prolene

left atrial suture placement facilitated by minimally invasive access

Minimally Invasive Supra-Annular MVR !!!