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Open Atrial TMVR in Mitral Annular Calcification
Study Questions:
What are the 30-day outcomes associated with a step-by-step technique for open atrial balloon-expandable transcatheter mitral valve replacement (TMVR) among patients with mitral annular calcification?
Methods:
A step-by-step description of the TMVR technique and outcomes of eight patients treated using this technique are described: using standard sternotomy or right thoracotomy, aortic cannulation and bicaval cannulation, and standard diastolic arrest with antegrade cardioplegia, the left atrium is opened in Waterston’s groove; the anterior mitral leaflet and supporting chords are excised and the posterior leaflet is retained; pledgeted 2-0 Ethibond sutures are placed around the circumference of the mitral annulus with pledgets on the atrial side, the native mitral annulus commissures are marked using an Edwards valve sizer, and guiding sutures are placed; the prepared and crimped valve is lowered into position; guiding sutures are slowly snared as the valve is inflated; three guiding sutures are secured with Cor-Knots; previously placed pledgeted 2-0 Ethibond sutures are passed through the TMVR stent frame and sealing skirt, and secured; customary de-airing and left atrial closure, removal of the cross-clamp, re-perfusion, and weaning from bypass. Baseline patient clinical and echocardiographic characteristics and 30-day post-TMVR outcomes are presented.
Results:
A cohort of eight patients underwent transatrial TMVR at a single institution. Five had undergone previous cardiac surgery. The mean Society of Thoracic Surgeons (STS) score was 8%. There was no in-hospital or 30-day mortality. Technical success by Mitral Valve Academic Research Consortium (MVARC) criteria and procedural success at 30 days both were 100%. Immediately after implantation, there was no or trace paravalvular leak in six patients, and mild paravalvular leak in one patient.
Conclusions:
The authors describe a technique that they found reproducible and associated with favorable outcomes in this early experience, and they suggest that it represents a useful technique for the treatment of mitral valve disease in the setting of severe annular calcification.
Perspective:
The treatment of patients requiring mitral valve replacement in the setting of severe mitral annular calcification remains a surgical challenge, often involving older patients with multiple comorbidities, and the potential for several surgical complications including prosthesis-patient mismatch secondary to valve undersizing, paravalvular leak, left circumflex coronary artery injury, and atrioventricular groove rupture. The authors describe a technique in which a balloon-expandable TMVR is placed via an open aortotomy, with apparently good short-term results.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation
Keywords: Calcinosis, Cardiac Surgical Procedures, Catheterization, Echocardiography, Geriatrics, Heart Arrest, Induced, Heart Valve Diseases, Heart Valve Prosthesis, Mitral Valve Insufficiency, Outcome Assessment, Health Care, Reperfusion, Stents, Sternotomy, Thoracotomy, Transcatheter Aortic Valve Replacement, Vascular Calcification
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