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Published on: May 26, 2023
Transatrial Balloon-Expandable Valve Implantation for Severe Mitral Annular Calcification With Native Leaflet Sealing
Omar Saleh1, Rishab Agarwal1, Israa Saleh1
1Eastern Virginia Medical School, Macon and Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia, USA.
Background:
Severe mitral annular calcification (MAC) limits mitral intervention options. Transseptal valve-in-MAC (ViMAC) transcatheter mitral valve replacement (TMVR) risks neo-left ventricular outflow tract (neo-LVOT) obstruction and paravalvular leak, while surgical replacement requires extensive annular reconstruction.
Case Summary:
We report 3 high-risk patients with severe MAC (computed tomography [CT]-based MAC scores 7-10) who underwent open transatrial valve-in-MAC TMVR via a balloon-expandable valve after CT-based simulation and multidisciplinary heart review identified increased risk of valve malapposition or neo-LVOT obstruction precluding transseptal approach. Native anterior mitral leaflet tissue was preserved, everted, and fixed to the bioprosthetic valve cuff, creating a seal to address frame-annulus gaps.
Discussion:
All patients achieved stable prosthesis apposition with no paravalvular leak, stable LVOT gradients, and significantly improved functional status at their 3-month follow-up. Two underwent concomitant aortic root replacement; one underwent concomitant septal myectomy and tricuspid repair.
Take-Home Messages:
CT-based simulation facilitates identification of patients who face increased risk of complications with transseptal TMVR. This series demonstrates reproducibility of native anterior mitral leaflet fixation to address frame-annulus gaps in transcatheter mitral replacement.
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