BVF and Mitral Valve-in-Valve with Surgical Resection of Mitral Prosthetic Valve Leaflets with Mitral SURPLUS

Transcatheter mitral valve-in-valve (ViV) is emerging as an alternative to surgery in patients with degenerated mitral valve bioprosthesis. One of the most common exclusion criteria for mitral ViV is left ventricular outflow tract obstruction (LVOTO) due to displacement of the anterior leaflet of the mitral valve prosthesis towards the septum, thus reducing the LVOT area. LVOTO needs to be prevented, and preoperative transesophageal echocardiography (TEE) and computed tomography angiography (CTA) play a crucial role in identifying the patients at risk. When not recognized on preoperative imaging, LVOT obstruction is a catastrophic complication of transcatheter mitral ViV procedure. 

Options to avoid LVOT obstruction include laceration of the anterior leaflet of the mitral valve (LAMPOON), septal ablation, or mitral ViV. If none of these techniques are feasible because of excessive calcification of the prosthetic leaflets or absence of a proximal septal branch, redo surgery and mitral valve replacement is the only option available. This is a challenging intervention that requires lysis of the adhesions, explantation of the existing bioprosthesis, and suturing of a new valve.

SURPLUS (surgical resection of prosthetic valve leaflets under direct vision) is a hybrid surgical and transcatheter technique that implies just the resection of the bioprosthetic valve leaflets, leaving the stent of the valve intact, and direct implantation of a balloon-expandable valve under direct vision and fluoroscopic guidance. SURPLUS can be performed via a right anterolateral thoracotomy, peripheral cannulation, and fibrillatory arrest. The left atrium is entered through the Sondergaard groove and the bioprosthetic leaflets are resected. In order to implant a larger transcatheter heart valve (THV) prosthesis, a bioprosthetic valve fracture (BVF) can also be performed using a noncompliant balloon. A balloon-expandable valve is then introduced and deployed under direct vision and fluoroscopic guidance in the standard fashion. 

SURPLUS avoids removal of the whole old mitral valve, thus shortening the duration of cardiopulmonary bypass (CPB) and cardiac ischemia. It is easy and reproducible, and is an option in the hands of surgeons when transcatheter ViV is not feasible because of high risk of LVOTO.

References

1. Basman C, Kliger C, Kodra A, et al. Transcatheter Mitral Valve-in-Valve With Surgical Resection of Bioprosthetic Valve Leaflets Under Direct Vision (Mitral SURPLUS). J Am Coll Cardiol Intv. 2022 Jun, 15 (12) e145–e146. https://doi.org/10.1016/j.jcin.2022.04.007

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