Transatrial Balloon-Expandable Valve Implantation for Severe Mitral Annular Calcification With Native Leaflet Sealing

Figures

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  Figure 1. Postprocedural Transesophageal Echocardiography Confirming Valve Position and Function (Patient 1) Two-chamber long-axis view demonstrating a well-seated 29-mm SAPIEN valve in mitral annular calcification with 80% atrial positioning with trace paravalvular leak.

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  Figure 2. Preoperative Imaging Demonstrating Caseous Mitral Annular Calcification (Patient 2) Noncontrast computed tomography demonstrating circumferential caseous mitral annular calcification affecting both posterior and anterior mitral valve leaflets. Severe left atrial enlargement is also observed. (A) Axial image demonstrating dense, bulky calcification along the posterior mitral annulus. (B) Circumferential extension of the calcific deposits, involving both the posterior and anterior annular segments. (C) Coronal long-axis view illustrating the longitudinal extent of the calcification along the annulus. (D) Coronal-oblique view further delineating the circumferential involvement of the mitral annular calcification.

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  Figure 3. DASI Preprocedural Simulation (Patient 2) (A) DLC/d ratio for the right coronary artery with a 26-mm SEV (DLC/d = 0.32), indicating high coronary obstruction risk. (B) Predicted TAV-TMV distance demonstrating proximity between aortic and mitral prostheses. (C) Neo-LVOT modeling with a 29-mm BEV in the mitral position yielding an acceptable predicted area (571 mm2). (D) Transcatheter heart valve apposition analysis demonstrating incomplete apposition due to irregular caseous calcification. BE = balloon-expandable; LVOT = left ventricular outflow tract; PVL = paravalvular leak; SE = self-expanding; TAV = transcatheter aortic valve; TMV = transcatheter mitral valve.

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  Figure 4. Intraoperative Technique (A) Primary chordae resected to mobilize the anterior mitral leaflet (AML), divided at A2 (arrow) and everted into the atrium with pledgeted horizontal mattress sutures. (B) The native AML fashioned as a sealing skirt and sutured to the valve's atrial cuff. (C) Pledgeted sutures at the commissural gaps to address residual defects.

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  Figure 5. Postprocedural Transesophageal Echocardiography Confirming Valve Position and Function (Patient 2) Two-chamber view demonstrating a well-seated 29-mm SAPIEN 3 valve-in-mitral annular calcification with approximately 90% atrial and 10% ventricular positioning.

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  Figure 6. DASI Preprocedural Simulation (Patient 3) Computed tomography–based computational simulation (DASI) modeling neo–left ventricular outflow tract (Neo-LVOT) area after virtual deployment of a 29-mm balloon-expandable valve with +3 cc overexpansion in the mitral position. BE = balloon-expandable.