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Minimally Invasive Direct Transcatheter Aortic Valve Replacement in Mitral Annular Calcification Implantation for Heavy Annular Calcification

Tuesday, January 14, 2020

Castillo-Sang M, Choo J. Minimally Invasive Direct Transcatheter Aortic Valve Replacement in Mitral Annular Calcification Implantation for Heavy Annular Calcification. January 2020. doi:10.25373/ctsnet.11569500.

The patient is an 80-year-old woman with severe mitral valve regurgitation and moderate-severe mitral valve stenosis who was evaluated for mitral valve replacement.  The patient had a mitraclip procedure performed two years prior and her mitral regurgitation had recurred. Her symptoms included fatigue and dyspnea on exertion.  She had prior coronary stents and her imaging studies demonstrated heavy mitral annular calcification (MAC), more prominent posteriorly and at the commissures.

Given her age, severe MAC, and the small annular sizel, the patient was felt to not be a good candidate for an operation for the resection of the calcium bar, so an alternative approach was seeked. After counseling the patient on an off-label balloon expandable transcatheter aortic valve in MAC, and after obtaining prior authorization and institutional approval for the procedure, the patient consented to this approach. The patient was offered a right minithoracotomy mitral valve operation. 

The operation was successful, with a 130 minute crossclamp. Twenty minutes of this time was spent constructing the composite TAVR valve felt/bovine pericardial composite on the back table. The patient was extubated six hours after arrival to the intensive care unit and had a 2-day stay in intensive care.  She had an uneventful recovery and was discharged on postoperative day seven. Her echocardiogram prior to discharge showed no residual mitral regurgitation and mean gradient of 2 mm Hg across the valve. 


Mitral valve replacement in severe mitral annular calcification represents a risky endeavor. The concern for AV-groove disruption is ever present. Removal of the calcium bar with patch reinforcement of the posterior annulus is not a simple technique. This technique carries a palpable risk for life-threatening complication, even with the most experienced surgeons. Newer techniques have been proposed to address severe MAC, and in six years, the use of a transcatheter aortic valve in the mitral position with different modifications has gain traction (1, 2, 3). The operation has been performed via sternotomy (4) and via a minimally invasive approach (1). 

Different modifications to the transcatheter balloon expandable valve have been described, but perhaps the most consistent is the suturing of the felt strip on the atrial side of the valve accompanied by a pericardial doughnut shaped washer. The rationale behind these two modifications is to minimize the risk for paravalvular leak and prevent valve migration.

A word of caution is warranted when performing this operation, and it is to factor in the time that it takes to construct the modifications on the back table. Sizing the valve using a balloon early on after resecting the anterior leaflet allows a second surgeon to perform the modification while the primary surgeon applies the annular sutures.

Direct implantation of a transcatheter aortic valve of a balloon expandable type in severe mitral annular calcification is safe and effective. It can be performed via sternotomy and minimally invasive approaches, such as right minithoracotomy. 


  1. Baumgarten H, Squiers JJ, Brinkman WT, DiMaio JM, Gopal A, Mack MJ, et al. Implantation of transcatheter aortic prosthesis in 3 patients with mitral annular calcification. Ann Thorac Surg. 2016;102(5):e433-e435.
  2. Praz F, Khalique OK, Lee R, Veeragandham R, Russell H, Guerrero M, et al. Transatrial implantation of a transcatheter heart valve for severe mitral annular calcification. J Thorac Cardiovasc Surg. 2018 Jul;156(1):132-142.
  3. Astarci P, Glineur D, De Kerchove L, El Khoury G. Transcatheter valve used in a bailout technique during complicated open mitral valve surgery. Interact Cardiovasc Thorac Surg. 2013 Oct;17(4):745-747.
  4. Lee R, Borchelt B, George I. Hybrid surgical mitral valve replacement with a transcatheter valve in the setting of mitral annular calcification. CTSNet. March 2018. doi:10.25373/ctsnet.5999933.


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Nice case. Curious, looks like the posterior annular sutures went in OK. 10 years ago would you have just placed a pericardial valve? Good to have more tricks in the tool box.
Thank you for sharing this video. However, this modification with the doughnut pericardial patch, in addition to circumferential stitches and the Teflon felt strip, makes the procedure unnecessary long for unclear benefit. The TAVI is self-anchoring after all and you would only need stitches where there is lack of calcium.
Thank you for your comments Gianluca and Kai. I had planned the procedure as a pericardial valve possible TAVR in valve. It would hinge on whether I would be able to fit in at least a 25 mm biological valve given patients’ BSA of 1.6. It wasn’t meant to be as the sizer for the 25 valve would not fit at all. At this point the the TAVR was implanted. The Teflon felt strip was the original idea and I think it works. In most cases. My concern was that I was not able to debride as good as I wanted some areas and was concerned about having to reapply the cross clamp in case of a moderate or severe paravalvular leak. That is why I chose the extra security. As this procedure becomes more common we will learn more best practices to supplant one surgeons concerns with actionable data.
I’ve performed over 2 dozen of these procedures. The last one was Tuesday of last week. My cross clamp time was 41 minutes. The difference is that immediately after cannulation, and before initiating CPB, I prep the TAVR valve on the back table. Size and amount of volume to be used for inflation is predetermined based on measurement of mitral annular volume from preop cardiac CTA and specialized software. I have had 100% procedural success with cross clamp time all under 60min. It is an excellent option for severe MAC that all surgeons should have in their tool belt.

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