Modified SAPIEN 3 (Edwards Lifesciences) for hybrid valve-in-MAC implantation.
Central Message.
Innovative surgical techniques continue to emerge in addressing the formidable challenges associated with mitral annular calcification.
Mitral annular calcification (MAC) remains a substantial challenge in mitral valve surgery. Given the high morbidity and mortality associated with this lesion, a myriad of approaches have been developed to address extensive MAC.1 Some surgeons favor “resection” techniques, including en bloc decalcification with annular reconstruction; however, this is met with considerable perioperative risk.2 We have previously reported on our approach to “respect” MAC with limited, if any, debridement to allow prothesis implantation. Our algorithm is dependent upon the distribution of annular calcification on preoperative computed tomography imaging. Calcification limited to the posterior annulus is approached with conventional surgical techniques.3 In more extensive, circumferential calcification, we favor a hybrid approach via direct-access, balloon-expandable device implantation, as demonstrated in this case video (Video 1). Informed written consent was obtained for this publication. No institutional review board approval is required at our institution for case reports.
We present a 66-year-old patient who was referred to us with New York Heart Associate class III symptoms. His history was notable for mantle-field radiation resulting in severe aortic stenosis and coronary artery disease status-post aortocoronary bypass and mechanical aortic valve replacement 20 years prior. Preoperative echocardiogram revealed severe mixed mitral stenosis and regurgitation with extensive MAC (Figure 1). Computed tomography angiography demonstrated severe circumferential MAC and a porcelain aorta (Figure 2). Given the large annular dimension and risk for left ventricular outflow tract obstruction, transcatheter intervention was not feasible, so hybrid implantation of a balloon-expandable SAPIEN 3 valve (Edwards Lifesciences) in the mitral position was performed. The surgery involved reoperative sternotomy, femoral cannulation, and transeptal mitral valve exposure under fibrillatory arrest. The anterior leaflet and its subvalvular apparatus were resected to reduce the risk of left ventricular outflow obstruction. The commissures were closed with pledgeted sutures to minimize paravalvular leak. The SAPIEN valve was wrapped in Teflon felt. The valve was loaded onto the delivery system and deployed while ensuring the frame was not protruding into the left ventricular outflow tract. Few valve sutures were placed at the anterolateral and posteromedial commissures to secure the cuff to the annulus to prevent migration. Postintervention echocardiogram demonstrated a well-seated mitral valve prothesis without paravalvular leak. The patient had an uneventful recovery. In summary, in selected patients with extensive MAC, direct-access hybrid mitral valve-in-MAC replacement using off-label, balloon-expandable devices can be safe and feasible.
Figure 1.
Transesophageal echocardiogram with preserved ventricular function, mixed severe mitral valve stenosis and regurgitation secondary to MAC, and a well-functioning mechanical aortic valve.
Figure 2.
Computed tomography of the chest demonstrated a porcelain aorta and extensive circumferential annular calcification.
Conflict of Interest Statement
Dr Tang has received speaker's honoraria and served as a physician proctor, consultant, advisory board member, transcatheter aortic valve replacement publications committee member, RESTORE study steering and screening committee member, APOLLO trial screening committee member, and IMPACT MR steering committee member for Medtronic; has received speaker's honoraria and served as a physician proctor, consultant, advisory board member, ENVISION trial screening committee member, and TRILUMINATE trial anatomic eligibility and publications committee member for Abbott Structural Heart; has served as an advisory board member for Boston Scientific; and has been a consultant for Shockwave Medical, Anteris, Philips, Edwards Lifesciences, Peija Medical, and Shenqi Medical Technology. All other 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.
Supplementary Data
Video available at: https://www.jtcvs.org/article/S2950-6050(26)00035-5/fulltext.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Video available at: https://www.jtcvs.org/article/S2950-6050(26)00035-5/fulltext.