Early outcomes of transatrial mitral valve replacement in severe mitral annular calcification

Figures

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  Transatrial mitral valve replacement in a patient with mitral annular calcification.

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  Figure 1. Intraoperative images of transatrial mitral valve replacement (TMVR). For high- or prohibitive-surgical risk patients with mitral annular calcification (MAC), a transatrial TMVR can be a safe and effective treatment option. This figure shows 6 distinct intraoperative steps for the successful execution of this procedure. After exposing the mitral valve, the anterior leaflet of the valve is excised to reduce the risk of left ventricular outflow tract (LVOT) obstruction (A). Next, annular sutures are placed, avoiding MAC when possible (B). Next the Sapien 3 valve (Edwards Lifesciences, Irvine, Calif) is prepped on the back table, first by reinforcing the valve skirt with a polytetrafluoroethylene felt strip (C) and then loading the valve on the delivery system with the skirt toward the handle (D). Finally, under direct visualization, the surgeon deploys the valve (E) and secures it in place by tying down the previously placed annular sutures (F). This technique allows the surgeon to address LVOT obstruction, paravalvular leak, and concomitant procedures at the time of MVR for these high-risk patients.

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  Video 1. Transatrial transcatheter mitral valve replacement (TMVR) intraoperative video. Shown is an operative video of the step-by-step sequence of transatrial TMVR performed in this present study. The video includes subtitles explaining each key step in this particular procedure. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00411-9/fulltext.

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  Figure 2. Step-by-step sequence for deploying Sapien 3 valve (Edwards Lifesciences, Irvine, Calif). Shown is the step-by-step sequence for deploying a Sapien 3 valve during transatrial transcatheter mitral valve replacement. The valve size will be predetermined based on preoperative computed tomography (CT). Once intraoperative, the valve size should be confirmed. Either simultaneously or in succession, the mitral valve leaflet can be resected and 2–0 pledgeted Ethibond (Johnson & Johnson, Franklin Lakes, NJ) sutures can be placed around the annulus. At the same time on the back table, the transcatheter heart valve (THV) should be reinforced with a polytetrafluoroethylene (PTFE) felt strip using 4–0 Prolene sutures. The THV can then be crimped and loaded onto the delivery system. Now that the annular sutures are in place and the THV is prepared, the THV should be deployed and the annular sutures should be secured through the THV skirt and secured with Cor-Knots (Litigation Solutions Inc, Greenwood Village, Colo). Once all of the sutures have been secured, the surgeon can inspect for paravalvular leak (PVL) using a saline test.