Robotic-Assisted Transatrial Balloon-Expandable Valve Placement in Severe Mitral Annular Calcification

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Clinical Vignette 

A 78-year-old male presented with worsening intermittent shortness of breath. Diagnostic imaging revealed severe mitral regurgitation with prolapse and extensive mitral annular calcification (MAC). A CT scan showed severe MAC with left atrial enlargement. Cardiac catheterization confirmed no obstructive coronary disease and moderately elevated pulmonary artery pressures. Following discussion at a multidisciplinary high-risk cardiology conference, the patient was deemed a candidate for robotic-assisted balloon-expandable valve (BEV) placement for severe MAC. 
 
Surgical Techniques 

Once cardiac arrest had been achieved, a left atriotomy was performed, exposing the heavily calcified mitral valve. The A2 segment of the anterior leaflet and associated chordae were excised. The annulus was circumferentially reinforced with a felt strip secured using Ethibond sutures to mitigate the risk of paravalvular leak. A balloon was used to size the annulus, followed by placement of a second felt layer to ensure a tight seal. A 29 mm Sapien 3 BEV was then placed within the annulus in a slightly atrialized position to minimize the risk of left ventricular outflow tract (LVOT) obstruction. The valve was deployed and secured in place using Cor-Knots. The valve was expanded further and a leak test revealed a small paravalvular leak, which was addressed with the placement of a pledgeted suture attached to the valve’s lattice. The valve was expanded one additional time, and a repeat leak test demonstrated a complete circumferential seal. 

After confirming the correct valve position and the absence of any residual paravalvular leak on TEE, the patient was weaned from CPB, and all incisions were closed. The patient’s postoperative recovery was uneventful, and he was discharged home on postoperative day six. The patient reported complete resolution of his symptoms during follow-up visits. 
 
Comments 

Mitral annular calcification (MAC) presents a significant operative challenge due to its association with advanced age, increased comorbidities, and higher perioperative risks. MAC is linked to structural valve dysfunction and elevated mortality following mitral valve surgery. Traditional approaches to treating MAC, including open surgical and transcatheter techniques, carry risks such as LVOT obstruction, valve embolization, conduction disturbances, and paravalvular leak—all of which contribute to increased patient morbidity and mortality (1,2). 

Balloon-expandable valves (BEVs) have emerged as a promising option for mitral valve replacement in the setting of severe MAC. However, existing methods often present significant technical and anatomical challenges. At the authors’ institution, a robotically assisted transatrial approach has been utilized to optimize outcomes. This technique facilitates precise valve deployment while minimizing complications such as LVOT obstruction and valve embolization. 

References

1. Guerrero M, Urena M, Himbert D, et al. 1-Year Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Mitral Annular Calcification. J Am Coll Cardiol. 2018;71(17):1841-1853. doi:10.1016/j.jacc.2018.02.054
2. Fox CS, Vasan RS, Parise H, et al. Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study. Circulation. 2003;107(11):1492-1496. doi:10.1161/01.cir.0000058168.26163.bc

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