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. 2023 Oct 20:22:1-12.
doi: 10.1016/j.xjtc.2023.10.009. eCollection 2023 Dec.

Contemporary surgical techniques for mitral valve replacement in extensive mitral annular calcification

Ahmed El-Eshmawi  1 , Gilbert H L Tang  1 , Erick Sun  1 , Sophia L Alexis  1 , Busra Cangut  1 , Dimosthenis Pandis  1 , Percy Boateng  1 , David H Adams  1
Affiliations

Contemporary surgical techniques for mitral valve replacement in extensive mitral annular calcification

Ahmed El-Eshmawi et al. JTCVS Tech. .

Abstract

Objectives: Mitral annular calcification remains a formidable lesion in cardiac surgery with significant perioperative morbidity and mortality, particularly when en bloc annular decalcification is implemented. Respect strategies and hybrid approaches have provided safe alternatives. We report the short-term results of our institution's experience with mitral valve replacement in patients with extensive annular calcification.

Methods: This is a retrospective review of 72 consecutive patients with extensive annular calcification who underwent open surgical mitral valve replacement from January 1, 2013, to September 31, 2022. Degree of annular calcification was graded as partial, horseshoe, or circumferential. We excluded patients with calcification involving less than one-third of the annulus and patients with rheumatic heart disease.

Results: Mean patient age was 71.6 ± 10.9 years, and 50 (69.4%) were female. There were 51 patients (70.8%) with New York Heart Association class 3 or greater and 47 patients (65.3%) with pulmonary hypertension. There were 41 patients (56.9%) with partial, 12 patients (16.7%) with horseshoe, and 19 patients (26.4%) with circumferential calcification. Fifty-six patients (77.8%) underwent conventional valve replacement. Sixteen patients underwent a hybrid procedure using balloon-expandable devices. Concomitant procedures were performed in 61 patients (84.7%). In-hospital mortality and 1-year survival were 3.57% and 82.8% in the standard valve replacement cohort and 25.0% and 54.7% in the hybrid cohort, respectively.

Conclusions: Conventional mitral valve replacement using respect strategies is safe and associated with good outcomes in patients with extensive annular calcification. Hybrid approaches using novel devices should remain as a bailout in select patients because of higher perioperative risks and poor short-term outcomes.

Keywords: annular calcification; hybrid valve replacement; mitral valve.

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Conflict of interest statement

D.H.A. is the National Co-Principal Investigator of the TRILUMINATE U.S. Pivotal Trial (Abbott), the ReChord FDA Pivotal Trial (NeoChord), the APOLLO FDA Pivotal Trial (Medtronic), and the CoreValve U.S. Pivotal Trial (Medtronic). The Icahn School of Medicine at Mount Sinai receives royalty payments from Edwards Lifesciences and Medtronic for intellectual property related to Dr Adams' involvement in the development of 2 mitral valve repair rings and 1 tricuspid valve repair ring. G.H.L.T. is a consultant and physician advisory board member for Medtronic and Abbott Structural Heart, a physician advisory board member for Boston Scientific and JenaValve, and a consultant for NeoChord, and has received speaker's honoraria from Siemens Healthineers and East End Medical. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

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Graphical abstract
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Algorithm for surgical management of patients with extensive MAC.
Figure 1
Figure 1
Anatomic analysis of MAC and feasibility of transcatheter valves using multidetector CT. Clockwise from top left: A, Intercommissural and anterior-posterior dimensions are determined. B, Aortomitral angle and a virtual transcatheter valve (Sapien 3, Edwards Lifesciences, LLC) are placed to assess the fitting inside the MAC and LVOT obstruction risk. C, Severity of MAC, using a clockface orientation, is determined, with 270 to 300 degrees deemed horseshoe and more than 300 degrees circumferential. D and E, Maximum calcium thickness and height with the MAC are calculated to determine the extent of anchoring with the transcatheter valve.
Figure 2
Figure 2
Mount Sinai algorithm for management of MAC, where C-MVR is done for partial (<270) MAC and H-TMVR is done for horseshoe and circumferential MAC (>270). MAC, Mitral annular calcification; MVR, mitral valve replacement; TMVR, transcatheter mitral valve replacement.
Figure 3
Figure 3
Modified anterior leaflet flip technique for C-MVR. Anterior leaflet disinserted (A) and anterior leaflet flipped toward posterior leaflet creating neo-annulus (B).
Figure 4
Figure 4
H-TMVR stepwise technique: Valve analysis showing horseshoe MAC (A), anterior leaflet resection (B), Sapien 3 valve wrapped in felt strips (C), valve balloon deployment (D), fully deployed valve (E), and 2-dimensional and 3-dimensional transesophageal echocardiography reconstruction demonstrating well-seated valve (F-H).
Figure 5
Figure 5
Surgical management of extensive mitral annular calcification. Utilizing CT imaging to delineate annular calcification anatomy can help identify patients who can undergo conventional mitral valve replacement. For those patients with more complex anatomy, transatrial hybrid transcatheter intervention can be a bailout strategy in anatomically feasible cases. C-MVR, Conventional mitral valve replacement; H-TMVR, hybrid transcatheter mitral valve replacement.
Figure E1
Figure E1
Learning curve for H-TMVR implantation. AV, Atrioventricular; LVOTO, left ventricular outflow tract obstruction.
Figure E2
Figure E2
Standard Kaplan–Meier curve comparing C-MVR and H-TMVR 1-year survival. H-TMVR, Hybrid transcatheter mitral valve replacement; C-MVR, conventional mitral valve replacement.
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See this image and copyright information in PMC

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