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Endoscopic Valve-in-ring Technique For Mitral Valve Replacement In Redo Surgery With Severe Mitral Annular Calcification
Johannes Spilka, Adel Sakic, Lukas Stastny, Felix Nägele, Leo Winter-Pölzl, Can Gollmann-Tepeköylü, Daniel Höfer, Michael Grimm, Nikolaos Bonaros.
Medical University Innsbruck, Innsbruck, Austria.
BACKGROUND:Redo mitral valve surgery in the presence of severe mitral annular calcification is associated with substantial operative risk and is frequently considered prohibitive. This video demonstrates a fully endoscopic valve-in-ring mitral valve replacement technique as a potential treatment option for selected redo patients who are unsuitable for conventional or transcatheter mitral interventions.
METHODS:A 75-year-old redo patient with radiogenic mitral valve disease following mediastinal radiation therapy and prior aortic valve replacement via sternotomy presented with severe calcified mitral valve stenosis. Preoperative echocardiography demonstrated a mitral valve area of 1.3 cm² with a mean transmitral gradient of 9 mmHg and mild mitral regurgitation. Computed tomography confirmed near-circumferential mitral annular calcification with extensive leaflet involvement. Surgery was performed through a right mini-thoracotomy with femoral cannulation under ventricular fibrillation. A semi-rigid annuloplasty ring was implanted onto the heavily calcified annulus to create a stable circumferential landing zone. Valve-in-ring mitral valve replacement was subsequently performed using a transcatheter balloon-expandable prosthesis. Commissural anchoring sutures were added to adapt the D-shaped ring geometry to the circular prosthesis and to reduce the risk of paravalvular leakage.
RESULTS:Valve implantation was completed with stable prosthesis positioning. Intraoperative transesophageal echocardiography demonstrated normal prosthetic valve function without relevant paravalvular leakage, no systolic prosthesis tilting, and no evidence of left ventricular outflow tract obstruction. Postoperative echocardiography confirmed preserved prosthetic valve function with a mean transmitral gradient of 5 mmHg and minimal paravalvular leakage without hemodynamic relevance. Postoperative computed tomography showed stable valve position with satisfactory anatomical results. The postoperative course included a prolonged intensive care unit stay; the patient subsequently recovered and was discharged to a peripheral hospital and later home.
CONCLUSIONS:Endoscopic valve-in-ring mitral valve replacement using a surgically implanted annuloplasty ring, a transcatheter balloon-expandable prosthesis, and additional anchoring sutures may represent a feasible and reproducible strategy for selected redo patients with severe mitral annular calcification who are unsuitable for conventional surgical or transcatheter mitral valve interventions.
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