Hybrid Surgical Mitral Valve Replacement With a Transcatheter Valve in the Setting of Mitral Annular Calcification

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.