Precision hybrid technique for direct SAPIEN-3 ultra™ implantation in extensive mitral annular calcification

Mitral valve surgery in patients with extensive mitral annular calcification remains challenging. Different surgical approaches have been described: from a complete decalcification and reconstruction of the mitral annulus to other techniques where a full debridement was avoided to minimize the risk of possible peri-operative complications. In the current era of transcatheter valve implantation, the issue of mitral annulus calcification has been addressed by some with the adoption of a hybrid technique, where a transcatheter aortic valve is implanted in mitral position, during open heart surgery. This technique is emerging as a treatment option for high-risk patients although it is still an off-label procedure and needs further standardization. We describe here our surgical technique to implant a SAPIEN-3 Ultra™ in mitral position, addressing some of the key points in the surgical technique: the appropriate sizing and the phase of deployment of the prosthesis.