Robot-Assisted Transcatheter Heart Valve Replacement In A Patient With Severe Mitral Annular Calcification
Umit A. Gullu, Sahin Senay, Muharrem Kocyigit, Egemen Ersin, Leyla Kilic, Ozlem Celik, Serra Dilara Ilhan, Cem Alhan.
Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey.
BACKGROUND:Severe mitral (MV) annular calcification represents a challenge that can significantly complicate MV repair or replacement and all surgical decalcification with valvular intervention strategies may result with life threatening complications. Here in this report, we present an alternative method in a patient who was treated with robot assisted surgery and underwent transcatheter MVR.METHODS:A 72 year old woman with severe mitral and tricuspid valve insufficiency accompanying severe mitral annular calcification was admitted for valve intervention. Following the preparation of the patient according to robotic MV intervention, left atriotomy was performed. Non calcified portions of the anterior mitral leaflet was resected. Posterior leaflet was left intact due to severe calcifications. Pledgeted sutures were placed around the anterior mitral annulus, whereas from the left atrial wall adjacent to the calcified tissues at the posterior site to secure the transcatheter heart valve (THV). A Teflon felt strip was sewn around THV stent to avoid paraprosthetic leak. Three sutures were placed to avoid embolization of THV. The THV was crimped over the balloon and delivery system. The THV system was delivered via transthoracic route (32 mm Myval, Meril Life Sciences), the balloon was inflated and THV deployed. After right atriotomy, tricuspid valve was replaced with a 33 mm biological valve. Then, the cross clamp was released and CPB was terminated. However, TEE showed immediate intraprosthetic severe mitral insufficiency. The insufficiency of prosthetic valve was attributed to the malposition of the stent frame caused by off label use of crimping THV with Teflon felt. CPB reinitiated and cross clamp was placed once again. Following reatriotomy, a new THV (32 mm) was placed inside of previous THV. After weaning of CPB, TEE showed normal functioning prosthetic valve without LV outflow tract obstruction.RESULTS:Related to renal insufficiency the patient underwent dialysis at post operative period. Due to metabolic asidosis but not cardiac reasons, the patient died at 4th day following surgery.CONCLUSIONS:Robot assisted transatrial direct vision catheter based valve implantation is a feasible alternative approach in patients undergoing MVR accompanying severe annular calcification.
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