Hybrid Surgery for Severe Mitral Valve Calcification: Limitations and Caveats for an Open Transcatheter Approach

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Biomaterials in Medicine

Background:

• Severe mitral stenosis with extensive mitral annular calcification (MAC) presents significant surgical challenges.
• Traditional surgical approaches carry risks such as prolonged surgery, ventricular rupture, and systolic anterior motion.
• Existing treatments often have limitations for patients with severe MAC.

Purpose of the Study:

• To evaluate a novel hybrid approach for mitral valve replacement in patients with severe mitral stenosis and extensive MAC.
• To reduce the risks of ventricular rupture, paravalvular leaks, and outflow tract obstruction.
• To assess the feasibility and early outcomes of this alternative surgical strategy.

Main Methods:

• A hybrid approach involving open implantation of an Edwards Sapien 3 prosthesis was performed on cardiopulmonary bypass in six female patients (mean age 76 ± 9 years).
• The technique included resection of the anterior mitral leaflet, placement of anchor sutures, and visual deployment of a balloon-expandable prosthesis.
• Concomitant procedures were performed in three patients.

Main Results:

• Mean cross-clamp time was 95 ± 31 min and cardiopulmonary bypass time was 137 ± 60 min.
• Perioperative TEE revealed typical gradients and clinically irrelevant paravalvular leakage in the anterior annulus in three patients.
• Mild to moderate gradients were noted in the left ventricular outflow tract; no cerebrovascular events or pacemaker implantations occurred. Survival to discharge was 83.3% at one year.

Conclusions:

• The "off-label" implantation of the Edwards Sapien 3 prosthesis using this hybrid approach is a viable bail-out option.
• This method is suitable for high-risk patients or those deemed inoperable due to extensive MAC.
• The approach may mitigate risks associated with conventional mitral valve surgery in complex cases.