Balloon-Expandable Transcatheter Mitral Valve Replacement Through Minimally Invasive Approach in Big MAC

Severe mitral annulus calcification (MAC) is associated with increased cardiovascular morbidity and mortality in patients undergoing mitral valve replacement. It poses a significant challenge for even the most experienced surgeons, and multiple techniques have been proposed to address this challenging problem. In high-risk patients, an alternative to conventional surgical techniques involves the placement of a balloon-expandable transcatheter valve either through a transapical, transseptal, or open surgical approach.Hybrid mitral valve surgery has emerged as a treatment option for mitral valve disease in patients unsuitable for standard mitral valve surgery. This report describes a versatile approach to a very complex condition using SAPIEN 3 aortic valves with surrounding bovine pericardial patch placed in the mitral position inserted through a minimally invasive approach.IntroductionCarpentier and Cols. have developed surgical techniques for patients with big MAC, (1) which affects between 8% and 15% of patients with mitral stenosis and increases with age, cardiovascular risk factors, and severe renal impairment. (2)The first transcatheter mitral replacement (TCMR) in humans was reported in 2013 with the use of a transapical approach (3). Since then, different surgical approaches have aimed to decrease the rates of complications associated with severe MAC, such as cardiac rupture at the atrioventricular junction, injury to the circumflex artery, calcium embolism, and rupture of the left ventricular free wall. Additionally, surgeons have a further challenge: significant calcification makes debridement and placement of transannular sutures very difficult. Extensive removal of MAC usually requires repair with an atrial sliding plasty or pericardial patch reconstruction, with a subsequent high-risk mortality rate.The goal of hybrid mitral procedures is to reduce complications and shorten the surgical duration. Patients previously considered nonsurgical candidates due to severe MAC and high surgical risk are now potential candidates for a hybrid procedure using this innovative surgical technique. Case PresentationA 75-year-old woman with worsening dyspnea (NYHA III-IV), congestive heart failure, and very limited ambulatory capacity was assisted at the authors’ center.The patient’s medical history included hyperlipidemia, hypertension, obesity (weight: 90 kg; height: 160 cm), coronary disease with stent placed in the right coronary artery one month before, and