Project description:Mitral annular calcification (MAC) is a degenerative process that can cause mitral valve stenosis. Conventional surgical mitral valve replacement (MVR) for MAC with mitral stenosis can be challenging and associated with significant risk. Open surgical MVR with a transcatheter valve can offer an alternative in select situations. When such a strategy is not feasible, a beating-heart, mini-thoracotomy MVR with a SAPIEN 3 transcatheter heart valve can be considered. The novel teaching point of this case is use of an alternative approach for managing severe mitral stenosis secondary to MAC, when conventional surgical and transcatheter strategies are not safe or possible.
Project description:BackgroundAlthough transcatheter technology has achieved some success in the field of mitral valves, the feasibility of applying it to patients with degenerated mitral valve bioprostheses (valve-in-valve, ViV), failure of mitral valvuloplasty (valve-in-ring, ViR) and serious mitral annulus calcification (vale-in-MAC, ViMAC) has not been effectively evaluated.MethodsBy searching published literature before December 5, 2020 in four databases, we found all the literature related to the evaluation of feasibility assessment of TMViV, TMViR and TMViMAC. Outcomes focused on all-cause mortality within 30 days, bleeding and LVOT obstruction.ResultsA total of six studies were included, and all of them were followed up for at least 30 days. After analysis of the ViV-ViR group, we obtained the following results: the all-cause mortality within 30 days of the ViV group was lower than that of the ViR group. Life-threatening or fatal bleeding was more likely to occur in the ViR group after surgery. At the same time, the ViR group was more prone to left ventricular outflow tract obstruction. However, in the ViMAC-ViR group, only the all-cause mortality within 30 days and stroke were statistically significant. In the indirect comparison, we found that TMViV had the best applicability, followed by TMViR. There were few TMViMAC available for analysis, and it requires further studies to improve the accuracy of the results.ConclusionTMViV and TMViR had good applicability and could benefit patients who underwent repeat valve surgery. The feasibility of TMViMAC needs to be further explored and improved.
Project description:Calcification of the mitral valve annulus is common in patients on dialysis. The growing number of individuals receiving dialysis has been accompanied by an increase in cases necessitating surgical intervention for mitral valve annulus calcification. In this report, we present a severe case characterized by bulky calcification of the mitral annulus, which was managed with mechanical mitral valve replacement. A 61-year-old man on dialysis presented with chest pain upon exertion that had persisted for 3 months. Cardiac echocardiography revealed severe mitral stenosis and regurgitation, accompanied by cardiac dysfunction. During surgery, an ultrasonic aspiration system was employed to remove the calcification of the mitral valve annulus to the necessary extent. Subsequently, a mechanical mitral valve was sutured into the supra-annular position. To address the regurgitation, the area surrounding the valve was sewn to the wall of the left atrium. Postoperative assessments indicated an absence of perivalvular leak and demonstrated improved cardiac function. The patient was discharged on postoperative day 22. We describe a successful mitral mechanical valve replacement in a case of extensive circumferential mitral annular calcification. Even with severe calcification extending into the left ventricular myocardium, we were able to minimize the decalcification process. This approach enabled the performance of mitral mechanical valve replacement in a high-risk patient on dialysis, thus expanding the possibilities for cardiac surgery.
Project description:A 57 year old female underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Mild iatrogenic mitral stenosis was noted intraoperatively. Attempts to reposition the device were hampered by aortic angulation. One year later, severe mitral stenosis was confirmed on transoesophageal echocardiography. It is important to recognise that iatorgenic mitral stenosis due to TAVR may progress over time. Care should be taken to minimise the risk of this rare complication.
Project description:Transcatheter mitral valve replacement (TMVR) is currently being investigated as a procedural alternative to surgical mitral valve repair or replacement (SMVR). Early data from first-in-man trials with current devices suggest that TMVR is technically feasible but carries a high mortality. This is substantially different from the early success transcatheter aortic valve replacement (TAVR) has seen and is related to complexities of the mitral valve anatomy, differences in pathology that require mitral valve replacement as well as the impact that mitral valve replacement has on physiology and cardiac function, irrespective of the modality by which the mitral valve is replaced. Importantly, in the case of TAVR, a less invasive method is offered to accomplish the same as the traditional surgical intervention. On the other hand, valve replacement is not the recommended treatment option for the majority of mitral valve disease, and in fact is avoided whenever possible during surgery given the shortened life expectancy and increased morbidity with mitral valve replacement. Another distinction between TAVR and TMVR is the etiology and natural progression of the underlying disease and driving factors for intervention that are vastly different between aortic and mitral valve disease. The primary aortic disease treated has been aortic stenosis, which has several etiologic factors that cause a similar physiologic dysfunction and risk. Aortic valve replacement leads to improved survival and quality of life. The primary mitral valve disease targeted is regurgitation, which occurs as a primary valve defect and as a secondary consequence of ventricular dysfunction. Primary mitral regurgitation is treated by valve repair with excellent long-term outcomes. Secondary regurgitation has poor long-term outcomes with current commonly used repair techniques and limited data exists showing that correction of the regurgitation improves survival. Adoption of TMVR will require overcoming the anatomic challenges as well as generating data that supports improved survival and/or quality of life.