Objectives
Mitral annular calcification during mitral valve replacement can result in significant complications. Surgical decalcification with atrial plasty or pericardial patch can lead to atrioventricular disruption. Here the authors show a novel technique using a transcatheter valve deployed during open surgery in the mitral valve position.
Methods
An 83-year-old female presented with a two-month history of lower extremity swelling, shortness of breath, and lethargy in NYHA class 4 heart failure. The echocardiogram showed severe aortic stenosis and severe mitral regurgitation, with mitral annular calcificaiton and a prolapsed P2 leaflet.
Results
She underwent replacement of her aortic valve with a bovine pericardial valve and open transcatheter replacement of the mitral valve. The anterior leaflet of the mitral valve was resected to reduce left ventricular outflow tract obstruction. Anterior annular sutures were placed, followed by posterior leaflet sutures away from the calcium. The annulus was sized using a 26 mm and 28 mm balloon. A 29 mm transcatheter valve was opened, and a 1 cm soft felt cuff was placed around the skirt of the valve. The commissures of the valve were marked on the felt cuff. The valve was oriented to avoid placement of the commissure in the left ventricular outflow tract. The valve was deployed under direct vision with the felt cuff on the atrial side of the annulus, minimizing the cuff material in the left ventricular outflow tract. The mitral valve sutures were passed through the felt cuff and tied down to prevent perivalvular leak. The patient was separated from cardiopulmonary bypass easily, with no signs of perivalvular leak and a left ventricular outflow tract gradient of 3 mm Hg.
Conclusion
The use of a transcatheter valve in the mitral position allowed the authors to avoid potential atrioventricular disruption. This hybrid approach to mitral annular calcificaiton can improve surgical results and allow high risk patients to have surgery to improve quality of life.
This educational content was originally presented during the STSA 64th Annual Meeting. This content is published with the permission of the STSA. For more information on the STSA and its next Annual Meeting, please click here.
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4 Comments
Dear Colleagues,
Thank you for this demonstration. You may be aware that we published some years ago probably one of the first case we performed in 2012.
We have now a 6 year follow-up with the first patient and the result is still very good with a perfect function of the Sapien valve without regurgitation or sign of degeneration. Since then, we have performed some additional cases with mixed results but altogether we encourage surgeons to implement this technique for highly complex mitral cases with circumferential calcification of a small mitral anulus.
References
Worldwide first surgical implantation of a transcatheter valved stent in mitral position
Carrel TP, Wenaweser P, Reineke S, Simon R, Eberle B, Windecker S, Huber C.
Cardiovasc Med 2012;15(06):202-205.
Surgical antegrade transcatheter mitral valve implantation for symptomatic mitral valve disease and heavily calcified annulus.
Langhammer B, Huber C, Windecker S, Carrel T.
Eur J Cardiothorac Surg. 2017;51:382-384.
Prof. Thierry Carrel
University Hospital Bern, Switzerland
Being an “old fashioned” heart surgeon, I’ve been truly abhorred by the data of CPB! Time: 167 min. Cross clamp time 131 min. In an elderly pts. One would wish to know the results of side effects of that prolonged CPB – especially on brain and kidney function… By the way what’s wrong with the flexible sizers and with three anchoring pledgetted stitches followed by 3 running sutures and the use of an prefabricated biological valve?
I’m strongly interested in innovation, but I agree with dr. Tarr comment, if you’re able to pass all that interrupted sutures should be possible a normal implant.
I have to agree with the comments above. This is a great technique if you can not place sutures and do a standard replacement. We have used this exact technique for truly calcified annuli that cannot receive sutures or be debrided easily and it works very well. In this situation you have used technology to make a straightforward operation longer, more complicated and riskier, not to mention much more expensive, than it should have been.