Totally Endoscopic Direct TAVR in MAC MVR and IVC Repair

In this CTSNet series, Dr. Mario Castillo-Sang presents innovative, totally endoscopic cardiac procedures for a variety of conditions. Stay tuned for more series videos in the coming weeks.  

The authors present a totally endoscopic approach for transcatheter aortic valve replacement (TAVR) direct implantation in mitral annular calcification (MAC) with an inferior vena cava (IVC) repair.  

The case involved a 64-year-old female with severe mitral annular calcification and severe stenosis as shown CT scan images. She complained of dyspnea on exertion and significant impediment to daily activities, with NYHA Class III. 

The authors offered the patient a totally endoscopic open-heart surgery, which they described to the patient as a possible tissue valve, a possible mechanical valve, and a possible TAVR in MAC as a last option. Their conversations with patients undergoing mitral surgery with severe MAC circles around the goal of implanting a valve that will be sufficiently large for the patient’s body surface area.  

With this, they explained that if they can apply all the annular sutures and enlarge the orifice of the valve to a size appropriate for the patient—27 mm or higher—then the surgical valve will be implanted. If the orifice is large enough for a 25 mm valve and all the sutures can be placed, then a mechanical valve will be implanted.  As a last resort, if not all the sutures can be placed or if the size of the orifice cannot accommodate a 25 mm mechanical valve, then a TAVR Sapien 3) will be implanted directly in an off-label fashion. The authors always have the Cavitron ultrasonic surgical aspirator (CUSA) available to circularize the annulus and enlarge the orifice. Their goal is not to remove the calcium bar but to circularize and enlarge the annulus. With this approach, they have had zero operative or one-year mortalities in more than 30 cases performed in the last three years. The rate of stroke has also been zero. They also use calcium piercing needles such as PremiCron or taper microtips.  
 
Totally Endoscopic Setup 

The working incision was a 2.5 cm incision in the fourth intercostal space, expanded with an extra-small soft tissue retractor and no rib spreader. The camera port was a 10 mm trocar in the third intercostal space. A 5 mm incision was made in the fourth anterior intercostal space for the atrial lift retractor. Femoral bypass was established via cutdown with direct arterial and venous cannulation. The aorta was dissected off the right pulmonary artery bluntly to create space for the cross-clamp, and the oblique sinus was opened bluntly. During this maneuver, a small tear was created in the posterior aspect of the superior vena cava (SVC), which was repaired with 4-0 polypropylene with RB needles. Once repaired, the heart was arrested with antegrade del Nido cardioplegia, and a cross-clamp was deployed in the chest. The left atrium was opened through the interatrial groove, and the valve was exposed using the HV winged retractor. 

A severely calcified annulus was found. The surgeons marked the annulus around the area of deepest calcium extension into the posterior ventricle, which was between 6 and 3 o’clock. 

The posterior annulus and valve were decalcified using ultrasonic emulsification, and the anterior leaflet was resected, along with areas of heavy calcification. Once the orifice was large enough to accommodate a 27 mm bovine tissue valve annulus, the annular valve sutures were placed using the calcium cutting needles, but they could not be placed safely in the 3-6 o’clock area given the severe density of the calcium.  

Due to these findings, the authors decided to implant a TAVR 29 mm S3, which was modified with a skirt of felt leaving a brim on the atrial side (hence the term Panama Hat). The valve was deployed under direct vision of the endoscope into the mitral annulus, and after ballooning it open, the previously applied 2-0 polyester sutures were passed through the body of the felt strip and secured with titanium fasteners. The valve underwent a static test, and once satisfied with the results, the left atrium was closed in one layer. A completion TEE showed no paravalvular leak and a mean gradient of 4mmHg. The patient was extubated in the operating room and was discharged home on postoperative day four. Upon follow-up at six months, the patient reported significant improvement, now categorized as NYHA class 1. 

Endoscopic cardiac surgery allows for the treatment of severe MAC through direct TAVR in MAC cases or the implantation of a surgical valve. The use of the CUSA has facilitated these operations, and the availability of the S3 valves has allowed management of even more vast MAC. Many have adopted this approach with ultrasonic decalcification with good success (1). Others have used a robotic-assisted approach for mitral MAC patients, while some have managed it with a direct vision minimally invasive approach (2, 3). This is the first video report of totally endoscopic mitral valve surgery for TAVR implantation in severe MAC, as well as the use of CUSA for MAC endoscopically. The back table modification of the balloon-expandable valve is an important part of the operation because it decreases the risk of paravalvular leaks and valve embolization. Recently, the author has preferred to leave the brim of the hat in the mid-portion of the valve to act as a sealing washer on the annulus. 

References

1. Numaguchi R, Takaki J, Nishigawa K, Yoshinaga T, Fukui T. Outcomes of mitral valve replacement with complete annular decalcification. Asian Cardiovascular and Thoracic Annals. 2023 Nov;31(9):775-80.
2. Loulmet DF, Ranganath NK, Neragi-Miandoab S, Koeckert MS, Galloway AC, Grossi EA. Advanced experience allows robotic mitral valve repair in the presence of extensive mitral annular calcification. The Journal of Thoracic and Cardiovascular Surgery. 2021 Jan 1;161(1):80-8.
3. Barbero C, Spitaleri A, Pocar M, Parrella B, Santonocito A, Bozzo E, Depaoli A, Faletti R, Rinaldi M. Handling extensive mitral annular calcification via a minimally invasive right mini-thoracotomy approach. Applied Sciences. 2023 Feb 16;13(4):2563.

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