Hybrid Surgery for Severe Mitral Valve Calcification: Limitations and Caveats for an Open Transcatheter Approach

Abstract

Background and Objectives: Mitral stenosis with extensive mitral annular calcification (MAC) remains surgically challenging in respect to clinical outcome. Prolonged surgery time with imminent ventricular rupture and systolic anterior motion can be considered as a complex of causal factors. The aim of our alternative hybrid approach was to reduce the risk of annual rupture and paravalvular leaks and to avoid obstruction of the outflow tract. A review of the current literature was also carried out. Materials and Methods: Six female patients (mean age 76 ± 9 years) with severe mitral valve stenosis and severely calcified annulus underwent an open implantation of an Edwards Sapien 3 prosthesis on cardiopulmonary bypass. Our hybrid approach involved resection of the anterior mitral leaflet, placement of anchor sutures and the deployment of a balloon expanded prosthesis under visual control. Concomitant procedures were carried out in three patients. Results: The mean duration of cross-clamping was 95 ± 31 min and cardiopulmonary bypass was 137 ± 60 min. The perioperative TEE showed in three patients an inconspicuous, heart valve-typical gradient on all implanted prostheses and a clinically irrelevant paravalvular leakage occurred in the anterior annulus. In the left ventricular outflow tract, mild to moderately elevated gradients were recorded. No adverse cerebrovascular events and pacemaker implantations were observed. All but one patient survived to discharge. Survival at one year was 83.3%. Conclusions: This “off label” implantation of the Edwards Sapien 3 prosthesis may be considered as a suitable bail-out approach for patients at high-risk for mitral valve surgery or deemed inoperable due to extensive MAC.

Minimally Invasive Surgery: Standard of Care for Mitral Valve Endocarditis

“…We were able to address the majority of patients with MV IE, including reoperations in nearly 30% of the cases and mitral annular calcification in one patient. Although technically challenging and in spite of alternative hybrid strategies to mitigate anatomical risks, we do not consider annular calcification an absolute contraindication per se for minithoracotomy, irrespective of IE [ 14 , 28 , 29 ]. Admittedly, however, the minimally invasive approach was not employed in all cases to treat IE during the study period since patients suspected of more extensive IE or operated on with an emergent or salvage indication, most commonly cardiogenic or septic shock, were addressed with conventional sternotomy.…”

Mitral Valve Replacement Adopting Chimney Technique in Mitral Insufficiency And Extensive Mitral Annular Calcification: A Case Report

“…Bagaev et al adopted a hybrid technique by integrating transcatheter and operative approaches during mitral valve replacement to avoid MAC debridement, including the initial anterior leaflet resection, anchor suture placement, and eventual visual deployment control of the balloon-expandable prosthesis. This novel technique could avoid massive MAC debridement and address issues of transcatheter-based valve replacement like paravalvular leakage and prosthesis dislocation risk [Bagaev 2022]. But this hybrid approach requires a principal operator with expertise in both transcatheter invention and surgery.…”