Hybrid double-valve replacement

摘要

Central MessageSurgical placement of a transcatheter valve in mitral annular calcification avoids pitfalls of open and transcatheter approaches.See Commentaries on pages 38, 39, and 41. Surgical placement of a transcatheter valve in mitral annular calcification avoids pitfalls of open and transcatheter approaches. See Commentaries on pages 38, 39, and 41. The presence of mitral annular calcification (MAC) has been reported to increase risk of perioperative morbidity and mortality in mitral valve replacement (MVR).1Cammack P.L. Edie R.N. Edmunds Jr., L.H. Bar calcification of the mitral anulus. A risk factor in mitral valve operations.J Thorac Cardiovasc Surg. 1987; 94: 399-404Abstract Full Text PDF PubMed Google Scholar With the advent of transcatheter MVR, many patients with MAC have been treated successfully with transcatheter valve deployment.2Guerrero M. Urena M. Himbert D. Wang D.D. Eleid M. Kodali S. et al.1-year outcomes of transcatheter mitral valve replacement in patients with severe mitral annular calcification.J Am Coll Cardiol. 2018; 71: 1841-1853Crossref PubMed Scopus (158) Google Scholar Access options include trans-septal, transapical, and transatrial. The “Achilles heel” of trans-septal and transapical access is left ventricular outflow tract obstruction (LVOTO), as valve deployment may displace the anterior mitral leaflet into the ventricular outflow tract, causing hemodynamic compromise. Interventional techniques such as the intentional laceration of the anterior mitral leaflet procedure have been devised to address this complication in patients at high or extreme risk for surgery.3Khan J.M. Babaliaros V.C. Greenbaum A.B. Foerst J.R. Yazdani S. McCabe J.M. et al.Anterior leaflet laceration to prevent ventricular outflow tract obstruction during transcatheter mitral valve replacement.J Am Coll Cardiol. 2019; 73: 2521-2534Crossref PubMed Scopus (66) Google Scholar For patients who are able to tolerate surgery, transatrial implantation of a transcatheter prosthetic allows for partial resection of the anterior leaflet to obviate the risk of LVOTO and valve implantation without debridement of calcium and subsequent risk of atrioventricular groove disruption. We herein report a surgical technique for minimally invasive, robot-assisted, transatrial mitral valve implantation using a balloon-expandable prosthetic. An 84-year-old female patient with a history of hypertension, hyperlipidemia, rheumatic fever, aortic stenosis, and mitral stenosis and regurgitation presented with progressive fatigue and dyspnea. Transthoracic echocardiography revealed an ejection fraction of 71%, mean aortic valve gradient of 27 mm Hg with aortic valve area of 0.90 cm2, and mean mitral valve gradient of 23 mm Hg. Computed tomography revealed severe, circumferential MAC (Figure 1). Society of Thoracic Surgeons Predicted Risk of Mortality was 5.49% for aortic valve replacement (AVR) and 8.66% for MVR. To minimize debridement of the mitral annulus and the risk of open surgery, the patient was offered minimally invasive, robotic-assisted deployment of a balloon-expandable valve in the mitral position, combined with transcatheter AVR. Preoperatively, her mitral valve was sized using measurements from her computed tomography scan (Figure 1). The procedure was undertaken in a hybrid operating suite. The left femoral vessels were cannulated for cardiopulmonary bypass. An Intraclude intra-aortic occlusion device (Edwards Lifesciences, Irvine, Calif) was used for clamping and cardioplegia (now recalled and suspended from use). The DaVinci SI system (Intuitive Surgical, Sunnyvale, Calif) was docked and used to access the left atrium. Robotic ports were 12 and 8 mm, for the camera and arm ports, respectively, and a 2-cm incision was made for delivery of the valve. As shown in Video 1, the A2 scallop of the mitral valve anterior leaflet was resected. Two felt strips were parachuted onto the mitral annulus over Gore-Tex sutures (W. L. Gore & Associates