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

Figures

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  Figure 1. Extensive calcification of the mitral annulus is present, with significant calcification of the posterior mitral leaflet in the forefront. The anterior mitral leaflet has already been excised. A 2–0 Ethibond Excel® Polyester suture has been placed through the left atrial wall at the postero-medial commissure.

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  Figure 2. Superficial decalcification of the posterior mitral leaflet in order to allow a relatively large opening to accommodate a bigger prosthesis. Also, a smoother residual surface of the posterior mitral leaflet contributes to reduce the risk of residual paravalvular leak.

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  Figure 3. A 25 mm balloon fits tightly into the annulus, therefore we have opted for a 26 mm valve. However, we have overfilled the balloon with 2 mL for a safer anchoring and to compensate the lack of calcium of the anterior mitral annulus.

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  Figure 4. The final deployment is orthogonal to the valvular plane and a few mm into the left atrium to reduce the risk of left ventricle outflow tract obstruction. The mitral annulus is still the level of outer skirt of the SAPIEN-3 Ultra™. The stitches are carefully passed through the SAPIEN-3 Ultra™ (in the usual fashion of conventional valve implantation) directed from inside to outside the valve skirt; the suture line at the base of the leaflets can be used as reference. In the picture, the head of the papillary muscles has been resected. This is useful in case of heavily calcified papillary muscles and small left ventricle.