International Society For Minimally Invasive Cardiothoracic Surgery

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Combined Sutureless Aortic Valve Replacement And Transcatheter Valve In Aortic Stenosis And Mitral Annular Calcification
Gry Dahle, Runar Lundblad, Jon Offstad, Kjell Arne Rein.
Rikshospitalet, OUS, Oslo, Norway.

Introduction Half of the patients referred for TAVI have mitral annular calcification (MAC). MAC is an independent risk factor for death and pacemaker, and a double valve procedure should be as simplified and as short as possible. A hybrid procedure with sternotomy, cardiopulmonary bypass, open transcatheter valve implantation in MAC and sutureless aortic valve may be a solution. Material and method Three patients, all female aged 30-82 years (median 80) were referred with highly symptomatic aortic stenosis and MAC. CT reconstruction was performed to evaluate the aorto-mitral angle and size of the mitral annulus. Cardiopulmonary bypass was established through a sternotomy. The anterior mitral leaflet was removed. Four to six pledget sutures were placed at the level of the atrial wall and myectomy was performed. A surgical sizer gave additional information on the size of the transcatheter valve to be used. A balloon expandable transcatheter valve was deployed under direct vision and the protrusion into left ventricular outflow tract could be evaluated through the aortotomy. Decalcification of the aortic annulus was performed before implanting the sutureless valve. Results All prostheses were deployed without paravalvular leakage and with acceptable pressure gradients. There were no early deaths or coronary obstruction. One patient had a cerebral stroke and one patient died after 30 days in multi-organ failure. One patient on large steroids had a cerclage detachment in the sternum treated with VAC and later pectoral muscle transposition. No new pacemaker was needed. Conclusion A hybrid procedure with balloon expandable transcatheter valve in MAC and sutureless aortic valve may be a treatment option for well-selected patients with bivalvular stenosis. Precautions have to be taken to prevent left ventricular outflow tract obstruction.
legend to figure 1CT reconstruction of the two implanted valves, Perceval in aortic position and Sapien 3 i mitral valve position


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