Drs. Christopher M. Sciortino and Matthew R. Summers detail a Transcatheter Mitral Valve Replacement (TMVR) in a high-risk patient with severe Mitral Annular Calcification (MAC). The case emphasizes procedural planning and intraoperative decision-making in managing complex MAC anatomy, reinforcing TMVR as a viable therapeutic option for patients contraindicated for surgical mitral valve replacement.
I'm Matthew Summers. I'm, uh, an interventional cardiologist and a structural heart physician with the Sterile Heart valve Center, the program director for structural heart do transcaheter aortic valve replacement and other structural heart minimally invasive minimally invasive procedures. I'm Christopher Scortino. I'm a cardiac surgeon here at Center Heart Hospital. I'm also the uh surgical director of the heart transplant program, program director of the advanced heart failure. Uh, service and run the shock program as well as the mechanical circulators work program here at Sendera. So we're, we're more commonly being in scenarios where one therapy, uh, be it structural hard minimally invasive or uh sternotomy and uh cardiothoracic in nature with, with an open procedure. Uh, are becoming, uh, more likely to occur in, in coincidence. So the needs for both of those, uh, may balance the risks of each of the individual procedures. And so we often come uh together in our valve center with more complex cases. Doctor Scortino takes on. The vast majority of those very complex cardiothoracic surgeries, and there's often scenarios where uh a taver or trans catheter approached by itself is actually a little bit riskier and the patient needs open procedures. There's also procedures where, um, open heart uh may have its own unique anatomic limitations and risks. And so in those scenarios, we, we, uh, collaborate and often do hybrid procedures and we're gonna present one of those cases for you today. So the, the lady that we're presenting and Doctor Scortina will go through the, the unique surgical techniques used in the surgical considerations. I was a 73-year-old female that came to us over, uh, heart failure, decompensated in the hospital, and she had polyvalvular disease at 73, she had some risk factors. She was. Uh, noted to have some pulmonary hypertension on her, her index admission with uh PA systolic pressures in the 60s, I mean PAs in the 40s, but it was in the setting of critical aortic stenosis radiants in the 60s across your aortic valve uh and concomitants severe aortic insufficiency, uh, as well as very, very uh severely calcified mitral valve, uh we call mitralannular calcification. And concomitant calcificic mitral stenosis from a catheter-based standpoint, her risk of undergoing tabber was substantial with regards to annular rupture just from the aortic valve standpoint, and she had really indications to get her aorta uh repaired as well, given dilation. Um, but, uh, in, in the setting of the high risks for catheter-based therapies and having available um surgeons that can do complex open heart surgery. Um, we initially deferred, uh, and, and went the round of evaluating her for polyvalular surgery. And Chris, uh, do you have any thoughts on, um, looking at her mitral valve in particular? I know the aortic valve for you is the, the easier of the two to, to take care of. Yes, so the patient had significant aortic valve pathologies including significant aortic root calcifications. And a dilated ascending aorta. From a surgical standpoint, this is relatively straightforward to repair surgically. The mitral valve also needed to tend to, but she did, as Doctor Sommer stated, have severe mitralannu calcification, which is the calcification that grows into the mitral annulus and for this patient also grew into the LV wall. Making it very challenging to deal with in an open surgical procedure. These cases can be overtly dangerous to deal with surgically, uh, because of what is called um annular rupture or uh atrioventricular separation or dissociation, which can be, uh, life-threatening, um, and have mortalities that if they happen, uh, can be as high as 75 to 100%. So from a surgical standpoint, she was proposed to risk for standard uh surgical valve replacement. Um, and so this patient really had no conventional options of reasonable risk, and that's where this procedure comes in. Right. At this point in the operation, I've deconstructed the root in the ascending aorta and have exposure. Of the mitral valve with static retractors, um, and what I think is important with this is we have a view that's not just of the mitral valve, uh, but also of the LV apex. Um, this part of the video just shows the amount of debris that I, um, took out of the aortic valve alien route. And that was the, the lesser of the, the, the calc you know, extent of calcification in her uh two valves. The Mac was quite a bit more, so demonstrating how much work would have had to go, uh, you'd have had to go through depot called the mitral valve. Yes, and this is preparing the valve and it's uh loaded in its delivery device. At this point, we have uh the valve prepared and uh Doctor Summers and I are um getting the valve ready to deploy. And so this part shows um the valve and the delivery device, uh, in the appropriate orientation and um. The uh placement of the safari wire just out of the delivery device so that we have that bumper, um, and then. The point with the pickups is demonstrating where our target is for delivery at the level of the annulus, the white part of the valve is um the skirt or cuff um to which the native valve and surrounding tissue will be sewn to block off any um leaks. One of the things that when we're doing these purely catheter-based transeptal, um. is that it's very difficult to control how ventricular or atrial you are during deployment, and you have to deploy under rapid pacing over the course of 10 seconds. And so with this, Doctor Scortino's got full control of the depth of the implant in relation to that ceiling skirt, and we can go literally as slow as we need to and make those adjustments in real time, which is what you're doing right here. So we're both looking at the valve as it is being deployed. I'm making macro micro adjustments. This is the valve being deployed, uh, with the balloon inflating. Just as we do in percutaneous approaches and. I'm guiding the valve where I want it to be as the valve tends to turn a little bit and making sure that it abuts where it needs to. And the valve is deflating, we pull out the delivery system and we have a deployed valve.
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