International Society For Minimally Invasive Cardiothoracic Surgery

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Endoscopic Mitral Valve Implantation with A Sapien 3 In Mitral Annular Calcification
Antonios Pitsis, Head of Cardiac Surgery, Christos Tourmousoglou, Nikolaos Mezilis, Nikolaos Nikoloudakis, Nikolaos Tsotsolis.
St. Luke's Hospital, Thessaloniki, Greece.

OBJECTIVE: We report a fully endoscopic implantation of a Sapien 3 transcatheter prosthesis which was used to treat a high risk patient with severe mitral valve disease and mitral annular calcification (MAC). This technique has all the advantages of the already reported full sternotomy transatrial technique plus the added advantage of the minimally invasive approach through a 3cm periareolar incision and the more precise transcatheter valve placement due to the excellent stereoscopic vision available today through the 3D endoscopes.
METHODS: A 61 y.o. lady was admitted with pulmonary oedema. She had a history of chronic renal failure on dialysis and aortic valve replacement with a mechanical prosthesis 4 years ago. A TEE showed torrential mitral valve regurgitation because of immobile and calcified posterior leaflet and extended MAC. Preoperative CT-scan confirmed extensive calcification of the ascending aorta, the aortic annulus and severe MAC which was forming an incomplete ring.Her STS mortality score was calculated as 19.1%.The patient was also not a candidate for a transapical or transfemoral TMVR due to the risk of left ventricular outflow tract obstruction (LVOT). Therefore a hybrid endoscopic approach was offered to the patient. The chest was entered through a 3cm right periareolar incision, in the 4th intercostal space. On full CPB, a left atriotomy was performed and the anterior mitral leaflet was excised and 3 anchoring annular sutures inserted at 12, 4 and 8 o'clock. The annulus was sized with a 26mm balloon and a 26mm Sapien 3 valve was positioned and inflated under 3D endoscopic vision, with care taken that the skirt of the valve was sitting against the annulus. Then the three anchoring sutures were passed through the stent and secured.
RESULTS: Postoperative TEE confirmed excellent function of the Sapien 3, without any paravalvular leaks or LVOT obstruction.
CONCLUSIONS: The patient was extubated on the 2nd postoperative day and had an uneventful recovery. She remains well and in class II 8 months after her discharge with normal Sapien 3 function on echocardiogram.

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