RECONSTRUCTIVE SURGERY OF AN EXTREMELY CALCIFIED MITRAL VALVE IN BARLOW DISEASE PATIENT – A CASE REPORT

Introduction:Mitral valve calcifications are frequent finding in the Barlow disease. This is makinkg mitral repair surgery even more demanding in already complex valve pathology. Case report: Fifty–five year old Barlow disease patient underwent mitral repair surgery due to posterior leaflet prolapse at P2 level and extensive posterior leaflet and annular calcifications as well. Prolapsed scalop was resected, while P1 and P3 scalops were detached from the annulus.After complete posterior annulus decalcification, so formedlarge atrio-ventricular defect was reconstructed with autologous pericardial patch and double suture line technique.P1 and P3 segments were reatched thereafter by sliding technique, and sutured with no strain. Annuloplasty was performed with saddle rigid ring No 36. Patient was discharged nine days after the surgery with just a trace of mitral reguritation. Conclusion:Annular decalcificaion and reconstruction in patients with calcified Barlow mitral disease is neccessary for safe and durable mitral valve repair surgery. Introduction Extremely enlarged and thick mixomatous leaflets, along with significant annular dilatation are the main features of the Barlow mitral valve disease. Excessive leaflet mobilityin these patients, results in micro traumas at the leaflet base. The healing processstimulates fibrous scar formation thereafter and annular calcifications in some patients. Adjecent leaflet and miocardial tissue could be affected by the calcification process as well (1,2). Therefore calcified posterior annulus, is not a rare finding in Barlow patients (3) and makes already complex reconstructive surgery more demanding. This is a case report of a patient who underwent succesful mitral repair surgery in spite of excessive posterior leaflet and annular calcifications. Case report Fifty–five year old patient was admited tothe hopsital for the chronic severe mitral insufficiency. He was in NYHA functional class III. Echocardiography exam revealed grade 4 mitral regurgitation due to posterior leaflet prolapse at P2 level. Prolpased segment was at the same time immobile due to severe calcifications that were extending down into the posterior annulus. Heart chambers were moderately enlarged. Left atriumwas 44 mm, while left ventricle end-systolic and end-dyastolic dimameters were 43 mm and 59 mm respectively. Left ventricle ejection fraction was 60 %. Patient had no history of rheumatsim or bacterial endocarditis as well. Surgery was performed through the median sternotomy. Valve anatomy and leaflet thickness confirmed the diagnosis of the Barlow disease. Posterior leaflet P2 scalop was prolapsing due to elongated and ruptured chordae, and was at same time rigid and immobile due to severe calcifications. Posterior anulus was severely calcifiedas well, Fig 1a. Prolapsed segment was excised while P1 and P3 scalops were detached from the anulus. Posterior annulus calcification were completely removedleaving a large gap betweenthe left ventricle and atrium,Fig 1b. The most demanding part of the procedure was a reconstruction of such an important atrioventricular discontinuity. Posterior annulus therefore, was repaired with 4 x 2 cm oval shape autologous pericardium, Fig 1c. Six separate pledgeted 4/0 „U“ stiches, were placed trough the lower rim of the pericardal patch,left ventricle myocardium, and thereafter pulledthrough the left atrial wall and tied on the left atrial side, Fig 2a.The upper rim of the pericardial patch wasthen sutured to the left atrial wall with 4/0 runnung polipropilenesuture,making quite a strong posterior annulus reconstruction, Fig 2b.P1 and P3 scalop were thereafter reatached to the reconstructed posterior annulus by the leaflet sliding technique and sutured with no strain.Anuloplasty was performed with N o 36 SJM Saddle ring, Saint Jude Medical, SAD, Fig 1d. Postoperative course was uneventful, and the patient was dicharged 9 days after the surgery with fully competent mitral valve, Fig 1d. Discussion Barlow disease is one of the most complex pathologies in the mitral repair surgery.When present, annular calcifications makes mitralreconstructive surgery even more demanding.Although there is a quite enough leaflet tissue forthe repair in these patients, leaflet mobility, pliability and overal repair durabilityas well could not be fully achieved without posterior annulus decalcification (4). This is a complex and risky procedure for two reasons. Firstly, we must take carein order to protect circumflex artery in atrio-venticular (AV) groove, Fig 2b. Secondly, we have to keep in mind that decalcification at this level creates an AVdefect (5,6), which, if not repaired properly, results in catastrophic bleedeng afterwards. We reduced a possibility to entrap the circumflex artery by placing every single „U“ stich under direct vision. Additional support for such a large AV defect repair was achived by aditional runing suture. Therefore, we found that double stich line pericardial patchtechnique we decribed iseffective inpreventing both adverse events, Fig 2. Furthermore, pliability of the new posterior anulus we created, provides elastic and solid base for the leaflet sliding suture, and annuloplasty ring stichesas well. Such a solid, but elastic anular reconstruction alows surgeon to acheive full leaflet mobility after the sliding plasty and to reduce the stress at leaflet base as well. Conclusion: Annulus calcifications in Barlow mitral valve disease has to be removed in order to obtain pliable and durable valve repair. Atrioventricular defect upon decalcification could be safely reconstructed with autologous pericardium reinforeced by double suture line technique.


Introduction
Extremely enlarged and thick mixomatous leaflets, along with significant annular dilatation are the main features of the Barlow mitral valve disease.Excessive leaflet mobilityin these patients, results in micro traumas at the leaflet base.The healing processstimulates fibrous scar formation thereafter and annular calcifications in some patients.Adjecent leaflet and miocardial tissue could be affected by the calcification process as well (1,2).Therefore calcified posterior annulus, is not a rare finding in Barlow patients (3) and makes already complex reconstructive surgery more demanding.This is a case report of a patient who underwent succesful mitral repair surgery in spite of excessive posterior leaflet and annular calcifications.

Case report
Fifty-five year old patient was admited tothe hopsital for the chronic severe mitral

Discussion
Barlow disease one of the most complex pathologies in the mitral repair surgery.When present, annular calcifications makes mitralreconstructive surgery even more demanding.Although there is a quite enough leaflet tissue forthe repair in these patients, leaflet mobility, pliability and overal repair durabilityas well could not be fully achieved without posterior annulus decalcification (4).This is a complex and risky procedure for two reasons.Firstly, we must take carein order to protect circumflex artery in atrio-venticular (AV) groove, Fig 2b .Secondly, we have to keep in mind that decalcification at this level creates an AVdefect (5,6), which, if not repaired properly, results in catastrophic bleedeng afterwards.We reduced a possibility to entrap the circumflex artery by placing every single "U" stich under direct vision.Additional support for such a large AV defect repair was achived by aditional runing suture.Therefore, we found that double stich line pericardial patchtechnique we decribed iseffective inpreventing both adverse events, Fig 2 .Furthermore, pliability of the new posterior anulus we created, provides elastic and solid base for the leaflet sliding suture, and annuloplasty ring stichesas well.Such a solid, but elastic anular reconstruction alows surgeon to acheive full leaflet mobility after the sliding plasty and to reduce the stress at leaflet base as well.

Conclusion:
Annulus calcifications in Barlow mitral valve disease has to be removed in order to obtain pliable and durable valve repair.Atrioventricular defect upon decalcification could be safely reconstructed with autologous pericardium reinforeced by double suture line technique.
insufficiency.He was in NYHA functional class III.Echocardiography exam revealed grade 4 mitral regurgitation due to posterior leaflet prolapse at P2 level.Prolpased segment was at the same time immobile due to severe calcifications that were extending down into the posterior annulus.Heart chambers were moderately enlarged.Left atriumwas 44 mm, while left ventricle end-systolic and end-dyastolic dimameters were 43 mm and 59 mm respectively.Left ventricle ejection fraction was 60 %.Patient had no history of rheumatsim or bacterial endocarditis as well.Surgery was performed through the median sternotomy.Valve anatomy and leaflet thickness confirmed the diagnosis of the Barlow disease.Posterior leaflet P2 scalop was prolapsing due to elongated and ruptured chordae, and was at same time rigid and immobile due to severe calcifications.Posterior anulus was severely calcifiedas well, Fig 1a.Prolapsed segment was excised while P1 and P3 scalops were detached from the anulus.Posterior annulus calcification were completely removedleaving a large gap betweenthe left ventricle and atrium,Fig 1b.The most demanding part of the procedure was a reconstruction of such an important atrioventricular discontinuity.Posterior annulus therefore, was repaired with 4 x 2 cm oval shape autologous pericardium, Fig 1c.Six separate pledgeted 4/0 "U" stiches, were placed trough the lower rim of the pericardal patch,left ventricle myocardium, and thereafter pulledthrough the left atrial wall and tied on the left atrial side, Fig 2a.The upper rim of the pericardial patch wasthen sutured to the left atrial wall with 4/0 runnung polipropilenesuture,making quite a strong posterior annulus reconstruction, Fig 2b.P1 and P3 scalop were thereafter reatached to the reconstructed posterior annulus by the leaflet sliding technique and sutured with no strain.Anuloplasty was performed with N o 36 SJM Saddle ring, Saint Jude Medical, SAD, Fig 1d.Postoperative course was uneventful, and the patient was dicharged 9 days after the surgery with fully competent mitral valve, Fig 1d.

Figure 1 .Figure 2 .
Figure 1.Intraoperative images.a) Massive leaflet calcification that extends down into the