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editorial
. 2024 Jul 8;1-2:100011. doi: 10.1016/j.xjse.2024.100011

Surgical or transcatheter mitral valve replacement with mitral annular calcification

Omar Toubat 1, Max Shin 1, Pavan Atluri 1,∗
PMCID: PMC13244708  PMID: 42305829

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A proposed algorithm for MVR with MAC.

Central Message.

Surgical, hybrid, and transcatheter approaches each maintain a critical and complementary role in the replacement of the mitral valve with MAC.

Mitral annular calcification (MAC) is a disease process characterized by the progressive, degenerative calcification of the fibrous support structure of the mitral valve.1 The prevalence of MAC is estimated to be 8% to 15% in the general population and significantly increases with age.2, 3, 4, 5 Other risk factors include female sex, hypertension, coronary or peripheral artery disease, metabolic syndrome, chronic kidney disease, Barlow's disease, Marfan's syndrome, and mediastinal radiation.1 Although the underlying mechanisms driving MAC formation and progression remain incompletely understood, its clinical implications are well recognized. Previous studies have shown MAC to be independently associated with increased cardiovascular and all-cause mortality.4,6,7 In addition, the presence of severe MAC among patients undergoing mitral valve replacement (MVR) has been associated with increased operative death and risk of catastrophic complications, including atrioventricular (AV) groove disruption and ventricular rupture.8 Given these challenges, there is significant interest in optimizing therapeutic interventions for mitral valve dysfunction in the setting of MAC. In this article, we discuss evolving surgical techniques and newly emerging transcatheter therapies for MVR with MAC and define a role for each approach in the management of this complex disease process and patient population.

Preoperative Assessment

Before determining an optimal approach to MVR with MAC, it is critical to conduct a thorough diagnostic and preprocedural assessment of both the mitral valve and the patient. Assessment of the mitral valve should begin with transthoracic echocardiography, because this is the preferred method for evaluating anatomic and hemodynamic characteristics of the valve.9 Although it can involve any part of the mitral valve apparatus, MAC most often remains localized to the posterior annulus (Figure 1).10 In most cases of mitral valve dysfunction, the presence of MAC itself is not the direct cause of the valvular pathology requiring intervention. However, in the subset of patients with MAC-related valvular dysfunction, isolated mitral regurgitation or mixed lesions are more prevalent than isolated stenosis.11 Therefore, a comprehensive echocardiographic analysis of the entire mitral valve apparatus is warranted to clearly define the mechanism of valvular dysfunction in each patient. If visualization is limited in transthoracic windows, then transesophageal echocardiography may provide a more detailed assessment of valve anatomy and dynamics.11 Functional assessment of the underlying left ventricle and identification of concomitant valvular lesions are also feasible by echocardiography and have important prognostic and therapeutic implications when planning mitral valve interventions.

Figure 1.

Figure 1

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Schematic representation showing the spatial distribution of MAC (adapted from Carpentier and colleagues10). MAC, Mitral annular calcification.

In addition to echocardiography, computed tomography (CT) has emerged as a critically important diagnostic modality in the assessment of MAC. Preoperative CT allows for a detailed characterization of the extent, severity, quality, and distribution of calcification.12 CT imaging also may be used to identify areas of central hypodensity associated with liquefactive necrosis of MAC, which is observed in caseous calcification of the mitral annulus. This less common variant of the MAC disease process can predispose to valvular dysfunction and contribute to thromboembolic events. Understanding the morphologic and spatial distribution of MAC is important not only for grading its severity but also for anticipating technical challenges associated with intervention.13 In particular, knowledge of the calcium's proximity to the left circumflex coronary artery, coronary sinus, and conduction system can help guide intraoperative decision-making to minimize risk of iatrogenic injury. Previous studies have shown that the left circumflex coronary artery tends to run closest to the mitral valve annulus between the anterolateral commissure and P1.14, 15, 16, 17, 18 Although there are currently no established criteria regarding a uniform “safe” distance between the left circumflex artery and the annulus in the setting of MAC, it has been suggested that distances less than 3.5 mm may increase risk of injury.17,18 Additional details regarding MAC height, density, trigone involvement, and circumferential distribution around the annulus are also informative for determining the viability of a surgical or transcatheter approach. Finally, electrocardiogram gating and multidetector enhancement of CT imaging allow for precise anatomic measurements and 3-dimensional reconstructions to predict valve sizing, positioning, and risk of left ventricular outflow tract obstruction (LVOTO), which is particularly important in planning for transcatheter valve implants.19, 20, 21

In parallel with multimodal imaging of the mitral valve and associated MAC, it is important to carefully consider patient-related factors that may determine candidacy for intervention and influence the decision to pursue a surgical versus transcatheter approach. This assessment is best performed by a multidisciplinary heart team involving cardiac surgeons and structural cardiologists. Risk stratification begins with a systematic analysis of the patient's history, symptoms, comorbidities, functional status, and need for concomitant procedures. In addition, a shared decision-making approach incorporating patient preferences and goals of care is prudent. Taken together, this preoperative imaging and clinical evaluation strategy allows for the pursuit of an optimal and personalized MVR approach for both the mitral valve and the patient with MAC.

Surgical Mitral Valve Replacement

For patients with appropriate operative risk and relatively favorable MAC characteristics, conventional mitral valve surgery remains the preferred therapeutic approach. Examples of favorable MAC characteristics include mild-to-moderate density, focal or less than 270-degree annular involvement, sufficient distance from adjacent structures (eg, left circumflex artery, conduction tissue), and minimal extension of calcium into the leaflets, left atrium, left ventricle, or aortomitral curtain.21 Given the well-established advantages of mitral valve repair over replacement, we believe the mitral valve should be repaired whenever possible, irrespective of the presence of concomitant MAC. A more extensive discussion of mitral valve repair techniques and outcomes in the setting of concomitant MAC has been described by numerous authors and is outside the scope of this commentary.22, 23, 24

Although others have described excellent outcomes with a “resect”-first approach to MAC using several techniques not mentioned here, our preferred approach for surgical MVR in MAC is to minimize unnecessary disruption of the annular calcium and preserve the integrity of the annulus when possible. This “respect”-first approach aims to avoid excessive annular debridement and reduce the risk of AV groove disruption and associated complications.25 After median sternotomy, the mitral valve is exposed through Sondergaard's groove. Other minimally invasive techniques, such as minithoracotomy or robotic approaches, are also possible depending on the comfort and preference of the operating surgeon. After mitral valve exposure, the anterior leaflet is excised while sparing anterior chordae. Interrupted annular sutures are then preferentially placed around calcium bars when possible or through areas of “soft” calcium deposits when necessary. The primary goals when positioning annular sutures are to maintain even force of tension on sutures, ensure that an adequately sized prosthetic valve will be well seated, and avoid inadvertent injury to adjacent structures.

When MAC precludes the ability to fit an adequately sized mitral valve prosthesis, then a conservative “resect” strategy will be pursued. In these cases, the annulus should be selectively decalcified with sharp dissection before excision of the anterior leaflet. At our institution, decalcification is performed with assistance of a cavitron ultrasonic surgical aspirator device (Integra LifeSciences). The cavitron ultrasonic surgical aspirator emits high-frequency ultrasound waves to induce cavitations and promote remodeling of the calcium, with minimal risk of fracture. Fragmented debris are irrigated and safely aspirated from the surgical field. Previous studies by our group and others have demonstrated ultrasonic debridement to be safe and effective, with low operative mortality, minimal risk of stroke, and low risk of AV groove disruptions at time of MVR with MAC.E1, E2, E3 After decalcification, excision of the anterior leaflet can then be performed to facilitate prosthetic valve placement or to serve as a patch to reinforce the posterior annulus. In circumstances in which the MAC prevents a stable seal between the valve and annulus, the surrounding pliable atrial tissue can be used to close the gap that may exist. After supra-annular implantation of the prosthesis, valve competence is assessed using standard pressurized saline injection testing. Intraoperative transesophageal echocardiography is also performed to evaluate prosthetic valve positioning, assess for paravalvular leaks (PVLs) and residual gradients, and examine the function of the adjacent aortic valve and underlying left ventricle.

Although primary suture closure is often sufficient for mild-to-moderate annular debridement, radical decalcification may necessitate annular reconstruction. Several techniques have been proposed, including Carpentier's left atrial release and sliding plasty,10 autologous or bovine pericardial patch,E4,E5 anterior leaflet transposition,E6 and extracellular matrix patch.E7 Overall, among patients deemed good operative candidates with favorable MAC characteristics, we advocate for a “respect”-first strategy, with selective decalcification performed by high-frequency ultrasound only as required for placement of an appropriately sized and seated prosthetic valve. Other “respect”-first techniques, such as intra-annular or intra-atrial prosthetic valve placement, should be considered with caution because of the possibility of implanting a smaller valve, elevated risk of PVL, and potential need for reoperation. Finally, given the high risk of morbidity and mortality, we believe that radical decalcification of MAC and annular reconstruction should only be pursued when necessary.

Hybrid Transcatheter Mitral Valve Replacement (Transatrial Valve-In-MAC)

In patients with a suitable operative risk profile, yet unfavorable MAC characteristics21 (eg, severe density, more than 270 degree annular involvement, extension of calcification into or in close proximity of adjacent structures), a hybrid approach involving the surgical (transatrial) implantation of the ballon expandable Sapien transcatheter aortic valve replacement prosthesis has been proposed (hybrid valve-in-MAC or ViMAC).E8 After surgical exposure of the mitral valve with institution of bicaval cardiopulmonary bypass, the anterior leaflet is excised and pledgeted annular sutures are placed on the atrial side of the valve.E9 The transcatheter valve prosthesis is reinforced with a strip of felt to minimize PVL and deployed into the mitral valve orifice under direct vision.E9 An early, multicenter experience of ViMAC outcomes demonstrated technical success in 72% of patients and 30-day mortality of 30%.E10 However, this initial study combined outcomes across transseptal, transapical, and transatrial (hybrid) approaches, limiting interpretation of the results. Since this early experience, outcomes from several more studies have been reported after transatrial ViMAC specifically, demonstrating significant improvements in technical success (91%-100%) and 30-day mortality (0%-27%).E9,E11, E12, E13, E14

Despite promising early results with hybrid ViMAC, there remain concerns regarding the incidence of valve-related complications, including a high rate of left ventricular outflow tract obstruction (LVOTO) (4%-18%), PVL (0%-38%), and valve embolization (0%-6%).E9, E10, E11, E12, E13, E14 This led to the identification of several anatomic and technical factors that may improve ViMAC procedural success. Moderate-or-greater calcium density, near circumferential involvement of annular calcification, absence of significant mitral annular dilation, and use of surgical felt reinforcement have been shown to facilitate anchoring of the valve, lowering the risk of PVL and valve embolization.21,E15 In addition, several factors have been shown to increase the risk of postprocedural LVOTO (Table 1).E16, E17, E18, E19 Although preoperative multidetector CT has helped predict the potential for LVOTO, techniques such as surgical anterior leaflet resection and septal myectomy/alcohol ablation at the time of transatrial ViMAC appear to be successful at minimizing the risk of this complication. Additional transcatheter techniques such as the balloon-assisted translocation of the mitral anterior leaflet (BATMAN) and laceration of the anterior mitral valve leaflet (LAMPOON) have been described in this context as well.E20,E21 Ultimately, hybrid TMVR appears to be an appropriate and evolving therapeutic option for select patients with reasonable operative risk and MAC characteristics typically unfavorable for conventional open MVR.E22

Table 1.

Summary of anatomic characteristics associated with increased risk of left ventricular outflow tract obstruction after surgical and transcatheter mitral valve interventions

Characteristic Surgical MVr/MVR Hybrid/transcatheter MVR
Aorto-mitral angle <120 degrees <120 degrees
Basal septal thickness >15 mm >15 mm
Coaptation to septum distance <25 mm <17.8 mm
Posterior leaflet height >15 mm -
LV EDD <45 mm <48 mm
Relative LV wall thickness - >0.38
Native LVOT area - <372 mm2
Neo-LVOT area - <170 mm2
Virtual transcatheter valve to septum distance - <5.5 mm
Expected LVOT area reduction - >63.5%
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MVr, Mitral valve repair; MVR, mitral valve replacement; LV, left ventricle; EDD, end-diastolic diameter; LVOT, left ventricular outflow tract.

Transcatheter Mitral Valve Replacement

Initial attempts at transcatheter mitral valve replacement (TMVR) came from the off-label use of Sapien transcatheter aortic valve replacement prostheses in the mitral position. However, in contrast to the circular anatomy of the aortic valve annulus, the mitral valve has a larger, D-shaped annulus with non-coplanar geometry that varies dynamically across the cardiac cycle. The mitral valve is also intimately related to the underlying left ventricle through a complex subvalvar apparatus, and maintenance of this valvular-ventricular interaction is critical for normal left heart function. These anatomic differences between the aortic and mitral valve led to lower rates of technical success delivering the Sapien valve in the mitral position, with relatively high incidences of device embolization, PVL, and LVOTO.E23,E24 Although several designated TMVR delivery systems have recently been developed,E25 including the Sapien M3 (Edwards Lifesciences) and Intrepid (Medtronic) devices, published data on the outcomes in the setting of severe MAC remain limited. Therefore, the focus of this discussion will be on the Tendyne valve (Abbott Structural), which has the greatest reported experience with MAC to date.

The Tendyne TMVR device is a self-expanding, fully retrievable porcine pericardial valve mounted within a D-shaped nitinol stent frame designed to mimic the normal anatomic configuration of the mitral valve annulus.E26 The valve is implanted through a transapical approach, anchored to the left ventricle via an apical pad and the left atrium through a sealing cuff. The initial feasibility study of the Tendyne delivery system in MAC was performed on 9 patients with concomitant severe MR.E26 Technical success was achieved in 89% of patients, and there was 1 postprocedural death due to complications associated with LVOTO.E26 Follow-up studies of Tendyne TMVR, including in “real-world” patients enrolled in the European TENDER registry, have demonstrated improvements in technical success (96%-100%) and acceptable 30-day mortality (5%-8%).E27, E28, E29 However, although rates of LVOTO (2%) were low in these cohorts, the incidence of postprocedural PVL (9%) was not insignificant.E27,E28 Given this early success, the Tendyne device is currently being studied in the SUMMIT trial (NCT 03433274), which aims to compare Tendyne TMVR with the MitraClip system for patients with moderate-to-severe mitral regurgitation or symptomatic mitral valve disease due to severe MAC. Early results from the SUMMIT-MAC arm were presented at the Transcatheter Cardiovascular Therapeutics Conference in 2023 and showed a technical success rate of 94% and 30-day mortality of 7%. Incredibly, there was no recurrent mitral regurgitation or PVL demonstrated in this small, early cohort. The complete results from the SUMMIT trial and follow-up studies will likely help to define a role for the Tendyne TMVR delivery system in the management of otherwise inoperable patients with severe MAC.

Conclusions

MVR in the setting of severe MAC remains a challenge for cardiac surgeons. In addition to the added technical complexity associated with these procedures, risk of catastrophic morbidity and mortality is significant. Given the considerable heterogeneity of both the MAC disease process and host patient characteristics, it is exceedingly unlikely that a single therapeutic approach to MVR in this cohort will uniformly yield good outcomes. As such, we propose a therapeutic algorithm that incorporates both mitral valve- and patient-specific factors and defines complementary roles for surgical, hybrid, and transcatheter replacement approaches (Figure 2).

Figure 2.

Figure 2

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A proposed algorithm for MVR with MAC. MAC, Mitral annular calcification; MVR, mitral valve replacement; EKG, electrocardiogram; AV, atrioventricular; LVOT, left ventricular outflow tract; TMVR, trancatheter mitral valve replacement; ViMAC, valve-in-MAC.

For patients with acceptable surgical risk and favorable MAC anatomy, open surgical MVR remains the preferred therapy. In these cases, the use of selective ultrasonic debridement can facilitate annular preservation and minimize complications associated with annular disruption. For patients with acceptable surgical risk and unfavorable MAC anatomy, the use of hybrid ViMAC appears to be a suitable alternative to conventional MVR. This approach allows the surgeon to address concomitant disease processes and apply adjunctive techniques to optimize valve positioning under direct visualization. Finally, for patients who are deemed inoperable with anatomic characteristics amenable to a transcatheter approach, early data suggest the use of designated TMVR devices may offer a promising solution, although additional studies are warranted. Ultimately, surgical, hybrid, and transcatheter techniques should each be incorporated into the mitral valve surgeon's therapeutic armamentarium when managing patients with MAC.

Webcast

You can watch a Webcast of this AATS meeting presentation by going to: https://www.aats.org/resources/tmvr-or-surgery-for-mac-6690#video.

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Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Footnotes

Read at the 104th Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, April 27-30, 2024.

Drs Toubat and Shin contributed equally to this article.

Dr Pavan Atluri is an Associate Editor. The editorial process for this paper was handled by Dr Kendra Grubb.

References

  • 1.Abramowitz Y., Jilaihawi H., Chakravarty T., Mack M.J., Makkar R.R. Mitral annulus calcification. J Am Coll Cardiol. 2015;66(17):1934–1941. doi: 10.1016/j.jacc.2015.08.872. [DOI] [PubMed] [Google Scholar]
  • 2.Fertman M.H., Wolff L. Calcification of the mitral valve. Am Heart J. 1946;31:580–589. doi: 10.1016/0002-8703(46)90004-x. [DOI] [PubMed] [Google Scholar]
  • 3.Kanjanauthai S., Nasir K., Katz R., et al. Relationships of mitral annular calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA) Atherosclerosis. 2010;213(2):558–562. doi: 10.1016/j.atherosclerosis.2010.08.072. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Fox C.S., Vasan R.S., Parise H., et al. Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study. Circulation. 2003;107(11):1492–1496. doi: 10.1161/01.cir.0000058168.26163.bc. [DOI] [PubMed] [Google Scholar]
  • 5.Savage D.D., Garrison R.J., Castelli W.P., et al. Prevalence of submitral (annular) calcium and its correlates in a general population-based sample (the Framingham Study) Am J Cardiol. 1983;51(8):1375–1378. doi: 10.1016/0002-9149(83)90315-6. [DOI] [PubMed] [Google Scholar]
  • 6.Ramaraj R., Manrique C., Hashemzadeh M., Movahed M.R. Mitral annulus calcification is independently associated with all-cause mortality. Exp Clin Cardiol. 2013;18(1):e5–e7. [PMC free article] [PubMed] [Google Scholar]
  • 7.Fukui M., Cavalcante J.L., Ahmed A., et al. Clinical outcomes of mitral valve disease with mitral annular calcification. Am J Cardiol. 2022;174:107–113. doi: 10.1016/j.amjcard.2022.03.041. [DOI] [PubMed] [Google Scholar]
  • 8.Kaneko T., Hirji S., Percy E., et al. Characterizing risks associated with mitral annular calcification in mitral valve replacement. Ann Thorac Surg. 2019;108(6):1761–1767. doi: 10.1016/j.athoracsur.2019.04.080. [DOI] [PubMed] [Google Scholar]
  • 9.Dal-Bianco J.P., Levine R.A. Anatomy of the mitral valve apparatus: role of 2D and 3D echocardiography. Cardiol Clin. 2013;31(2):151–164. doi: 10.1016/j.ccl.2013.03.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Carpentier A.F., Pellerin M., Fuzellier J.F., Relland J.Y. Extensive calcification of the mitral valve anulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996;111(4):718–729. doi: 10.1016/s0022-5223(96)70332-x. [DOI] [PubMed] [Google Scholar]
  • 11.Churchill T.W., Yucel E., Deferm S., Levine R.A., Hung J., Bertrand P.B. Mitral valve dysfunction in patients with annular calcification: JACC review topic of the week. J Am Coll Cardiol. 2022;80(7):739–751. doi: 10.1016/j.jacc.2022.05.032. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Higgins J., Mayo J., Skarsgard P. Cardiac computed tomography facilitates operative planning in patients with mitral calcification. Ann Thorac Surg. 2013;95(1):e9–e11. doi: 10.1016/j.athoracsur.2012.07.059. [DOI] [PubMed] [Google Scholar]
  • 13.Guerrero M., Wang D.D., Pursnani A., et al. A cardiac computed tomography-based score to categorize mitral annular calcification severity and predict valve embolization. JACC Cardiovasc Imaging. 2020;13(9):1945–1957. doi: 10.1016/j.jcmg.2020.03.013. [DOI] [PubMed] [Google Scholar]
  • 14.Virmani R., Chun P.K., Parker J., McAllister H.A., Jr. Suture obliteration of the circumflex coronary artery in three patients undergoing mitral valve operation. Role of left dominant or codominant coronary artery. J Thorac Cardiovasc Surg. 1982;84(5):773–778. [PubMed] [Google Scholar]
  • 15.Hiltrop N., Bennett J., Desmet W. Circumflex coronary artery injury after mitral valve surgery: a report of four cases and comprehensive review of the literature. Catheter Cardiovasc Interv. 2017;89(1):78–92. doi: 10.1002/ccd.26449. [DOI] [PubMed] [Google Scholar]
  • 16.Coutinho G.F., Leite F., Antunes M.J. Circumflex artery injury during mitral valve repair: not well known, perhaps not so infrequent-lessons learned from a 6-case experience. J Thorac Cardiovasc Surg. 2017;154(5):1613–1620. doi: 10.1016/j.jtcvs.2017.05.043. [DOI] [PubMed] [Google Scholar]
  • 17.Miura K., Komiya T., Shimamoto T., Matsuo T. How far is the left circumflex coronary artery from the mitral annulus? Gen Thorac Cardiovasc Surg. 2020;68(12):1447–1452. doi: 10.1007/s11748-020-01493-1. [DOI] [PubMed] [Google Scholar]
  • 18.Caruso V., Shah U., Sabry H., Birdi I. Mitral valve annulus and circumflex artery: in vivo study of anatomical zones. JTCVS Tech. 2020;4:122–129. doi: 10.1016/j.xjtc.2020.09.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Eleid M.F., Foley T.A., Said S.M., Pislaru S.V., Rihal C.S. Severe mitral annular calcification: multimodality imaging for therapeutic strategies and interventions. JACC Cardiovasc Imaging. 2016;9(11):1318–1337. doi: 10.1016/j.jcmg.2016.09.001. [DOI] [PubMed] [Google Scholar]
  • 20.Blanke P., Dvir D., Cheung A., et al. A simplified D-shaped model of the mitral annulus to facilitate CT-based sizing before transcatheter mitral valve implantation. J Cardiovasc Comput Tomogr. 2014;8(6):459–467. doi: 10.1016/j.jcct.2014.09.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Guerrero M.E., Grayburn P., Smith R.L., II, et al. Diagnosis, classification, and management strategies for mitral annular calcification: a heart valve collaboratory position statement. JACC Cardiovasc Interv. 2023;16(18):2195–2210. doi: 10.1016/j.jcin.2023.06.044. [DOI] [PubMed] [Google Scholar]
  • 22.Ng C.K., Punzengruber C., Pachinger O., et al. Valve repair in mitral regurgitation complicated by severe annulus calcification. Ann Thorac Surg. 2000;70(1):53–58. doi: 10.1016/s0003-4975(00)01347-3. [DOI] [PubMed] [Google Scholar]
  • 23.d'Alessandro C., Vistarini N., Aubert S., et al. Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome. Eur J Cardiothorac Surg. 2007;32(4):596–603. doi: 10.1016/j.ejcts.2007.06.044. [DOI] [PubMed] [Google Scholar]
  • 24.Elde S., Zhu Y., MacArthur J.W., Woo Y.J. Surgical management of severe mitral annular calcification. Asian Cardiovasc Thorac Ann. 2023;31(4):297–302. doi: 10.1177/02184923221136935. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Saran N., Greason K.L., Schaff H.V., et al. Does mitral valve calcium in patients undergoing mitral valve replacement portend worse survival? Ann Thorac Surg. 2019;107(2):444–452. doi: 10.1016/j.athoracsur.2018.07.098. [DOI] [PubMed] [Google Scholar]

E-References

  1. Baumgartner F.J., Pandya A., Omari B.O., et al. Ultrasonic debridement of mitral calcification. J Card Surg. 1997;12(4):240–242. doi: 10.1111/j.1540-8191.1997.tb00133.x. [DOI] [PubMed] [Google Scholar]
  2. Weininger G., Green J., Mori M., Geirsson A. Cavitron ultrasonic surgical aspirator for mitral annular decalcification. Multimed Man Cardiothorac Surg. 2021;2021 doi: 10.1510/mmcts.2021.009. [DOI] [PubMed] [Google Scholar]
  3. Brescia A.A., Rosenbloom L.M., Watt T.M.F., et al. Ultrasonic emulsification of severe mitral annular calcification during mitral valve replacement. Ann Thorac Surg. 2022;113(6):2092–2096. doi: 10.1016/j.athoracsur.2021.11.066. [DOI] [PubMed] [Google Scholar]
  4. Feindel C.M., Tufail Z., David T.E., Ivanov J., Armstrong S. Mitral valve surgery in patients with extensive calcification of the mitral annulus. J Thorac Cardiovasc Surg. 2003;126(3):777–782. doi: 10.1016/s0022-5223(03)00081-3. [DOI] [PubMed] [Google Scholar]
  5. Mihaljevic T., Koprivanac M., Kelava M., Smedira N.G., Lytle B.W., Blackstone E.H. Mitral valve replacement in patients with severely calcified mitral valve annulus: surgical technique. J Thorac Cardiovasc Surg. 2013;146(1):233–235. doi: 10.1016/j.jtcvs.2013.02.034. [DOI] [PubMed] [Google Scholar]
  6. Casselman F.P., Gillinov A.M., McDonald M.L., Cosgrove D.M., III Use of the anterior mitral leaflet to reinforce the posterior mitral annulus after debridement of calcium. Ann Thorac Surg. 1999;68(1):261–262. doi: 10.1016/s0003-4975(99)00337-9. [DOI] [PubMed] [Google Scholar]
  7. Arbona M.A., David T.E., David C.M., Rao V. Results of mitral valve reconstruction using substitute extracellular matrix. JTCVS Tech. 2022;16:43–48. doi: 10.1016/j.xjtc.2022.09.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Wilbring M., Alexiou K., Tugtekin S.M., et al. Pushing the limits-further evolutions of transcatheter valve procedures in the mitral position, including valve-in-valve, valve-in-ring, and valve-in-native-ring. J Thorac Cardiovasc Surg. 2014;147(1):210–219. doi: 10.1016/j.jtcvs.2013.09.021. [DOI] [PubMed] [Google Scholar]
  9. Kawano Y., Newell P., Harloff M., et al. Early outcomes of transatrial mitral valve replacement in severe mitral annular calcification. JTCVS Tech. 2021;9:49–56. doi: 10.1016/j.xjtc.2021.06.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Guerrero M., Dvir D., Himbert D., 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):1361–1371. doi: 10.1016/j.jcin.2016.04.022. [DOI] [PubMed] [Google Scholar]
  11. Praz F., Khalique O.K., Lee R., et al. Transatrial implantation of a transcatheter heart valve for severe mitral annular calcification. J Thorac Cardiovasc Surg. 2018;156(1):132–142. doi: 10.1016/j.jtcvs.2018.03.016. [DOI] [PubMed] [Google Scholar]
  12. Lamelas J., Alnajar A. Early outcomes for surgical minimally invasive SAPIEN 3 transcatheter mitral valve replacement. Ann Thorac Surg. 2021;112(2):494–500. doi: 10.1016/j.athoracsur.2020.09.024. [DOI] [PubMed] [Google Scholar]
  13. Smith R.L., Hamandi M., Ailawadi G., et al. Surgical implantation of balloon-expandable heart valves for the treatment of mitral annular calcification. J Thorac Cardiovasc Surg. 2023;166(1):62–70. doi: 10.1016/j.jtcvs.2021.08.047. [DOI] [PubMed] [Google Scholar]
  14. Brener M.I., Hamandi M., Hong E., et al. Early outcomes following transatrial transcatheter mitral valve replacement in patients with severe mitral annular calcification. J Thorac Cardiovasc Surg. 2024;167(4):1263–1275.e3. doi: 10.1016/j.jtcvs.2022.07.038. [DOI] [PubMed] [Google Scholar]
  15. Millar J.K., Ailawadi G. Current techniques for severe mitral annular calcification. JTCVS Tech. 2023;22:53–58. doi: 10.1016/j.xjtc.2023.10.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Varghese R., Itagaki S., Anyanwu A.C., Trigo P., Fischer G., Adams D.H. Predicting systolic anterior motion after mitral valve reconstruction: using intraoperative transoesophageal echocardiography to identify those at greatest risk. Eur J Cardiothorac Surg. 2014;45(1):132–137. doi: 10.1093/ejcts/ezt234. [DOI] [PubMed] [Google Scholar]
  17. Bapat V., Pirone F., Kapetanakis S., Rajani R., Niederer S. Factors influencing left ventricular outflow tract obstruction following a mitral valve-in-valve or valve-in-ring procedure, part 1. Catheter Cardiovasc Interv. 2015;86(4):747–760. doi: 10.1002/ccd.25928. [DOI] [PubMed] [Google Scholar]
  18. Yoon S.H., Bleiziffer S., Latib A., et al. Predictors of left ventricular outflow tract obstruction after transcatheter mitral valve replacement. JACC Cardiovasc Interv. 2019;12(2):182–193. doi: 10.1016/j.jcin.2018.12.001. [DOI] [PubMed] [Google Scholar]
  19. El Sabbagh A., Al-Hijji M., Wang D.D., et al. Predictors of left ventricular outflow tract obstruction after transcatheter mitral valve replacement in severe mitral annular calcification: an analysis of the transcatheter mitral valve replacement in mitral annular calcification global registry. Circ Cardiovasc Interv. 2021;14(10) doi: 10.1161/CIRCINTERVENTIONS.121.010854. [DOI] [PubMed] [Google Scholar]
  20. Helmy T., Hui D.S., Smart S., Lim M.J., Lee R. Balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction (BATMAN): a novel technique for patients undergoing transcatheter mitral valve replacement. Catheter Cardiovasc Interv. 2020;95(4):840–848. doi: 10.1002/ccd.28496. [DOI] [PubMed] [Google Scholar]
  21. Khan J.M., Babaliaros V.C., Greenbaum A.B., et al. Anterior leaflet laceration to prevent ventricular outflow tract obstruction during transcatheter mitral valve replacement. J Am Coll Cardiol. 2019;73(20):2521–2534. doi: 10.1016/j.jacc.2019.02.076. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Awtry J.A., Shi W.Y., McGurk S., et al. National trends in utilization of transatrial transcatheter mitral valve replacement and postoperative outcomes. J Thorac Cardiovasc Surg. 2023 doi: 10.1016/j.jtcvs.2023.10.010. [DOI] [PubMed] [Google Scholar]
  23. Tiwana J., Aldea G., Levin D.B., et al. Contemporary transcatheter mitral valve replacement for mitral annular calcification or ring. JACC Cardiovasc Interv. 2020;13(20):2388–2398. doi: 10.1016/j.jcin.2020.07.007. [DOI] [PubMed] [Google Scholar]
  24. Guerrero M.E., Eleid M.F., Wang D.D., et al. 5-year prospective evaluation of mitral valve-in-valve, valve-in-ring, and valve-in-MAC outcomes: MITRAL trial final results. JACC Cardiovasc Interv. 2023;16(18):2211–2227. doi: 10.1016/j.jcin.2023.06.041. [DOI] [PubMed] [Google Scholar]
  25. Kietrsunthorn P.S., Ghrair F., Schelegle A.R., Foerst J.R. Transcatheter mitral valve therapies in patients with mitral annular calcification. Interv Cardiol Clin. 2024;13(2):237–248. doi: 10.1016/j.iccl.2024.01.002. [DOI] [PubMed] [Google Scholar]
  26. Sorajja P., Gössl M., Babaliaros V., et al. Novel transcatheter mitral valve prosthesis for patients with severe mitral annular calcification. J Am Coll Cardiol. 2019;74(11):1431–1440. doi: 10.1016/j.jacc.2019.07.069. [DOI] [PubMed] [Google Scholar]
  27. Gössl M., Thourani V., Babaliaros V., et al. Early outcomes of transcatheter mitral valve replacement with the Tendyne system in severe mitral annular calcification. EuroIntervention. 2022;17(18):1523–1531. doi: 10.4244/EIJ-D-21-00745. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Wild M.G., Kreidel F., Hell M.M., et al. Transapical mitral valve implantation for treatment of symptomatic mitral valve disease: a real-world multicentre experience. Eur J Heart Fail. 2022;24(5):899–907. doi: 10.1002/ejhf.2434. [DOI] [PubMed] [Google Scholar]
  29. Hell M.M., Wild M.G., Baldus S., et al. Transapical mitral valve replacement: 1-year results of the real-world Tendyne European experience registry. JACC Cardiovasc Interv. 2024;17(5):648–661. doi: 10.1016/j.jcin.2023.12.027. [DOI] [PubMed] [Google Scholar]

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