Transatrial Balloon-Expandable Valve Implantation for Symptomatic Mitral Stenosis With Severe Annular Calcification—A Hybrid Solution

ABSTRACT

Background: Treatment of symptomatic mitral valve stenosis in severe mitral annular calcification is a surgical challenge. Transcatheter options include transfemoral transcatheter mitral valve replacement (TMVR), which poses its own risks, the most significant is left ventricular outflow tract (LVOT) obstruction. Transatrial hybrid TMVR optimizes advantages of both traditional open-heart surgery and transcatheter valve replacement. Methods: Retrospective review of seven high-risk patients (deemed ineligible for traditional surgery) undergoing transatrial implantation of a SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA) in the mitral position for severe symptomatic mitral stenosis. Laceration of the Anterior Mitral leaflets to Prevent Outflow ObstructioN procedure was not considered due to heavy leaflet calcifications. Results: Seven patients treated consecutively from June 2020 to July 2021 were included in this analysis. Mean age was 77 years;six were females, one was male. Average STS score was 9.8. Three patients had New York Heart Association (NYHA) class IV heart failure. Mean left ventricular ejection fraction was 62%. Dominant mitral valve pathology included mitral stenosis in all patients. Mean mitral valve gradient was 12 mmHg. All patients had circumferential annular calcification except one, who had predominantly anterior calcification. All patients received the Edwards SAPIEN 3 valve and had anterior leaflet resection. Surgical approach was at the discretion of the attending cardiac surgeon. Mean cardiopulmonary bypass time was 85 minutes;mean cross-clamp time was 36 minutes. No anchoring felt was used. Technical success was 100%, with no device embolization. There was no clinically significant LVOT obstruction. There were two deaths one occurred during index hospitalization due to worsening heart failure secondary to torrential tricuspid regurgitation, and the second was 2 months later due to COVID-19 infection. Conclusion: Surgical hybrid transatrial TMVR for patients at high surgical risk is technically feasible with high procedure success. A relatively shorter cardiac ischemic duration, direct visualization and resection of the anterior mitral leaflet can allow for safe TMVR without risk of LVOT obstruction.