The double-meaning of MAC: mitral annular calcification or a nice burger.
Central Message.
Open transcatheter valve implantation for mitral annular calcification seems a reasonable solution in selected patients, but results may depend on comorbidities.
See Article page 254.
Mitral annular calcification (MAC) can be a major problem during surgery for patients with mitral valve disease who require replacement solutions. MAC is frequently present in the aging mitral valve, and it has been estimated that within a few decades the increase in the average age of the population will translate into an increase in its prevalence.1 Therefore, new approaches are needed to further expand the potential treatment of these patients.
In the current issue of the Journal, Hamid and colleagues2 reviewed 1-year outcomes of open transcatheter mitral valve implantation (TMVI) for MAC with off-label use of the Edwards balloon-expandable SAPIEN 3 Bioprosthesis (Edwards Lifesciences, Irvine, Calif). The study includes an elegant description of technical considerations that need to be addressed when performing a TMVI in a MAC (Figure 1), based on the authors' institutional experience in managing complications, including paravalvular leaks, annular prosthesis mismatch, left ventricular outflow tract obstruction, and myocardial perforation due to calcific limbs. The authors described satisfactory results when compared with other transatrial TMVI registries and superior results when compared with TMVI registries for trans-septal or transapical approaches. In addition, an analysis of treated and untreated patients showed significant improvement in the New York Heart Association class in the implanted group, despite a greater mortality rate.
Figure 1.
Mitral annular calcification (MAC) can be a major problem during surgery for patients with mitral valve disease.
The authors are to be commended for their work. However, a generous part of the paper has been dedicated to a comparison with other studies. Unfortunately, most of the conclusions are still speculations, and some questions remain unanswered. In particular, the authors did not provide a detailed explanation of the significantly prolonged hospital stay of their patients. Also, from a technical perspective, some uncertainties remain regarding the implantation of an annuloplasty ring in case of annular–prosthesis mismatch. This, in fact, would not overcome the limitation of a calcified native ring and the need of a firm anchoring of the expandable valve. Finally, a more in-depth study of the technique should be conducted, especially considering the importance of patient's profile stratification, assuming that early outcomes depend on patient-related comorbidities.
Nevertheless, there is no doubt that this study provides another example of how innovative techniques can be used to improve the limitations of standard approaches. Consequently, we can only conclude with a famous wish that also applies to our field (and when it comes to Big MACs): “stay hungry, stay foolish.”
Footnotes
Disclosures: 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.
References
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