Combined transfemoral TAVI and direct-vision valve-in-MAC through the transaxillary approach

Clinical vignetteA 70-year-old female with a history of hypertension, paroxysmal atrial fibrillation, previous ischemic stroke, and extensive atherosclerotic disease was referred to our center for symptomatic severe rheumatic aortic stenosis (mean gradient 43 mmHg) with severe aortic regurgitation and hemodynamically significant rheumatic mitral stenosis (mean gradient 8-9 mmHg).She presented with New York Heart Association (NYHA) class III symptoms, with preserved left ventricular systolic function (LVEF 60%).Preoperative transthoracic echocardiography and multiplanar computed tomography (CT) reconstruction confirmed a heavily calcified aortic valve alongside massive, circumferential calcification of the mitral annulus extending into the posterior leaflet [severe mitral annular calcification (MAC)]; the ascending aorta also exhibited diffuse calcifications.Due to the severe aortic calcifications and the patient's very high surgical risk profile, conventional surgery via full sternotomy was deemed to carry an unfavorable risk-benefit ratio (1).Following a comprehensive Heart Team evaluation, a tailored minimally invasive hybrid surgical strategy was planned: transfemoral transcatheter aortic valve implantation (TAVI) followed by direct transatrial valvein-MAC via a right transaxillary minithoracotomy (2); the latter was selected over a fully percutaneous transseptal approach to allow direct resection of the anterior mitral leaflet [reducing the risk of left ventricular outflow tract (LVOT) obstruction, otherwise predicted on preprocedural CT scan] and to safely manipulate the calcified annulus under direct vision while minimizing systemic calcium embolization risk.Indeed, preoperative CT virtual valve simulation (using 3mensio software) demonstrated a predicted Neo-LVOT area with an intact anterior leaflet critically reduced at 125.9 mm 2 , while the resection would have expanded the predicted Neo-LVOT area to a safe threshold of 240.8 mm 2 .The CT-derived mitral annular area was 8.6 cm 2 .