Severe Mitral Annular Calcification Research Articles

Transapical Mitral Valve Replacement: 1-Year Results of the Real-World Tendyne European Experience Registry

BackgroundEarly studies of the Tendyne transcatheter mitral valve replacement (TMVR) showed promising results in a small selective cohort. ObjectivesThe authors present 1-year data from the currently largest commercial, real-world cohort originating from the investigator-initiated TENDER (Tendyne European Experience) registry. MethodsAll patients from the TENDER registry eligible for 1-year follow-up were included. The primary safety endpoint was 1-year cardiovascular mortality. Primary performance endpoint was reduction of mitral regurgitation (MR) up to 1 year. ResultsAmong 195 eligible patients undergoing TMVR (median age 77 years [Q1-Q3: 71-81 years], 60% men, median Society of Thoracic Surgeons Predicted Risk of Mortality 5.6% [Q1-Q3: 3.6%-8.9%], 81% in NYHA functional class III or IV, 94% with MR 3+/4+), 31% had “real-world” indications for TMVR (severe mitral annular calcification, prior mitral valve treatment, or others) outside of the instructions for use. The technical success rate was 95%. The cardiovascular mortality rate was 7% at 30 day and 17% at 1 year (all-cause mortality rates were 9% and 29%, respectively). Reintervention or surgery following discharge was 4%, while rates of heart failure hospitalization reduced from 68% in the preceding year to 25% during 1-year follow-up. Durable MR reduction to ≤1+ was achieved in 98% of patients, and at 1 year, 83% were in NYHA functional class I or II. There was no difference in survival and major adverse events between on-label use and “real-world” indications up to 1 year. ConclusionsThis large, real-world, observational registry reports high technical success, durable and complete MR elimination, significant clinical benefits, and a 1-year cardiovascular mortality rate of 17% after Tendyne TMVR. Outcomes were comparable between on-label use and “real-world” indications, offering a safe and efficacious treatment option for patients without alternative treatments. (Tendyne European Experience Registry [TENDER]; NCT04898335)

Ultrasonic Emulsification of Severe Mitral Annular Calcification to Enable Mitral Valve Repair.

Ultrasonic Emulsification of Severe Mitral Annular Calcification to Enable Mitral Valve Repair.

Mitral valve replacement using a collar-reinforced mitral prosthesis for severe mitral annular calcification, which secures implantation in both the supra-annular and intra-atrial positions: a case report

BackgroundAppropriate management of mitral annular calcification associated with mitral valve surgery must be determined on a case-by-case basis. However, an established procedure remains uncertain.Case presentationThis report describes a surgical case of severe mitral and aortic valve stenosis associated with severe mitral annular calcification in a 71-year-old woman who underwent mitral valve replacement with a collar-reinforced mitral prosthesis. The patient underwent surgical repair after the treatment for heart failure. As the present patient was deemed to be at high risk for conventional mitral valve replacement, we applied a composite prosthetic valve that was enlarged circumferentially on the ventricular side of the prosthesis with a bovine pericardial patch. First, the solid calcium bar was left untouched and only the friable calcified mass that was easily scattered was removed. Subsequently, the prosthesis was secured by two mattress sutures placed in the intra-atrial position at the region of the extended calcified myocardium. Additionally, ten mattress sutures were placed in the supra-annular position at the other regions capable of passing stitches from the ventricular side to the atrial side. Finally, a 1.5 cm wide trimmed bovine pericardial collar was sutured circumferentially from the annulus to the atrial wall using running 4–0 polypropylene for reinforcement. Although temporary hemodialysis was performed for acute renal failure, the patient remained asymptomatic.ConclusionsThe present case suggests that mitral valve replacement using a collar-reinforced mitral prosthesis may be an effective technique for severe mitral annular calcification. To avoid catastrophic complications associated with treatment for severely calcified annulus, it is crucial to make a prudent preoperative decision regarding the surgical strategy under circumstances where conventional mitral valve replacement is impossible.

Mitral annular calcification in patients with severe aortic stenosis underwent transcatheter aortic valve implantation: prevalence and association with stenosis severity

Abstract Background Patients with calcific aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) usually have calcification in other cardiac structures, especially mitral annulus. Severity of mitral annular calcification (MAC) and degree of mitral stenosis (MS) may be associated with hemodynamic effects and outcomes. Purpose We sought to investigate the prevalence of MAC in patients with severe calcific AS using mitral annular calcium score with Agatston method from cardiac computerized tomography (CT). We also aim to assess the severity grading of MAC and its association with the severity of MS evaluated by transthoracic echocardiography. Methods We conducted a retrospective cohort analysis of the TAVI registry at King Chulalongkorn Memorial Hospital between May 2013 and December 2021. Clinical information was extracted from medical records. The pre-TAVI echocardiography and cardiac CT were reviewed, as well as the mitral annular calcium score. The severity of MAC (no, mild, moderate, severe) was classified using cardiac CT per the modified Cleveland clinic classification system. The MS grading was based on the 2009 American society of echocardiography guidelines. MAC prevalence was studied. Analysis of the association between MAC and MS was conducted. Results Our cohort included a total of 188 patients (mean age of 81±8 years). 134 patients (71.3%) demonstrated evidence of MAC. 47 patients (25%) had severe MAC evaluated by cardiac CT. Among patients with severe MAC, mean age was 83±8 years, 29 patients (63%) were female, 14 patients (30%) had diabetes, and 11 (23%) of them were associated with moderate or severe MS. Patients with MAC were significantly associated with hemodynamically significant MS (moderate or severe) when compared with patients without MAC (p <0.001). Conclusions One-fourth of patients with severe calcific AS underwent TAVI had severe MAC. The hemodynamically significant MS was more prevalent as the severity of MAC increased. The association between MAC and long-term adverse clinical outcomes needs to be further investigated.Figure 1Figure 2

Abstract 18312: Is the Presence of Multiple Valvular Heart Disease or Mitral Annular Calcification in Cancer Patients Exposed to Chest Radiotherapy or Chemotherapy That Underwent Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis Associated With MACE?

Introduction: Multiple Valvular Heart Disease (VHD), defined as at least moderate stenotic or regurgitant lesions in ≥2 valves, mixed VHD as combination of lesions in the same valve and mitral annular calcification (MAC) are common conditions. Association between multiple-mixed VHD (MMVHD), MAC and MACE in patients exposed to Radiation Therapy (RT) and/or chemotherapy (CT) who underwent Transcatheter Aortic Valve Replacement (TAVR) has not been studied. Aim: Assess the presence of MMVHD and MAC in cancer patients with prior RT and/or CT and their correlation with MACE (cardiovascular death, myocardial infarction, revascularization, stroke and hospitalization for heart failure) after TAVR. Methods: 544 patients were included and divided into 3 groups: 187 with prior chest RT and CT (RT/CT), 155 CT only, and 202 without CT/RT as controls (Table 1). Data was obtained from the pre-procedure echocardiogram and quantified in a 1-6 scale (none, mild, mild/moderate, moderate, moderate/severe and severe). Fisher’s exact test or chi-square were used to compare categorical. Multiple VHD-MACE correlation was evaluated through multivariable Cox analysis using a proportional hazards model. Results: The prevalence of Multiple VHD was 37.4% in RT/CT, 23.2% in CT, and 13.9% in controls p<0.001(Figure 1). The RT/CT group had a significantly higher prevalence of severe MAC. Multiple VHD predicted MACE at 18 months after TAVR in RT/CT (HR 3.42, CI 1.93-6.08, p<0.001) and in CT (HR 2.55, CI 1.39-4.66, p=0.002) (Table 2). In RT/CT, severe MAC also predicted MACE (HR 3.68, CI 2.13-6.37, p<0.001), while it was not a predictor in the other groups. Stenotic or regurgitant VHD was more prevalent in the RT/CT group (Figure 2). Conclusions: Multiple VHD was found higher in RT/CT and predicted MACE at 18 months post-TAVR, including CT only patients. Severe MAC was also a strong predictor of the outcome in RT/CT patients. Pre-TAVR evaluation of MMVHD lesions is crucial for optimal patient management.

Abstract 18273: Mitral Annular Calcification is Associated With Higher Operative Risks and Worse Survival in Hypertrophic Cardiomyopathy

Background: Mitral annular calcification (MAC) is common in hypertrophic cardiomyopathy (HCM), usually accompanied by mitral leaflet calcification, subvalvular apparatus calcification, and mitral valve dysfunction. However, the impact of MAC on surgical strategy and clinical outcomes in HCM is not fully understood. Methods: This cohort enrolled 1035 consecutively recruited patients diagnosed with HCM between January 2016 and December 2021. All patients received a computed tomographic scan prior to surgery. Results: Of the 1035 patients, 112 (10.8%) had MAC, including 39 patients with moderate or severe MAC (calcification area greater than one-third of the annulus). Patients with MAC were significantly older (59.6±8.2 years vs. 47.5±12.3 years, p<0.001) and more likely to be female (61.8% vs. 35.4%, p<0.001). Echocardiography showed a higher proportion of mitral leaflet thickening (17.9% vs. 6.0%, p<0.001) in patients with MAC. Moreover, patients with MAC had a higher rate of annular reconstruction (1.79% vs 0.11%, p=0.002), plastic ring implantation (5.36% vs 1.84%, p=0.017), chordae release (12.50% vs 5.09%, p=0.002), artificial neochordoplasty (2.68% vs 0.54%, p=0.015), and fibrous membrane removal (8.93% vs 4.12%, p=0.022), as well as longer ventilation time [19 hours, interquartile range (IQR) 17.0-26.0 vs. 18 hours, IQR 14.0-20.5, p<0.001], intensive care unit stay [61 hours, IQR 36.5-96.0 hours vs. 48 hours IQR 24.0-72.0 hours, p<0.001] and postoperative hospital stay [8days, IQR 7-11 days vs. 7 days, IQR 6-8 days, p<0.001]. During a median follow-up time of 26.2 months (IQR, 17.0 to 39.5 months), 5 death and 158 major adverse cardiovascular events (MACE) were observed. Kaplan-Meier survival curves showed that patients with MAC had a higher cumulative rate of all-cause mortality (p=0.026) and MACE (p=0.003) compared to their counterparts. On multivariable Cox regression analysis, moderate or severe MAC was an independent risk factor for MACE (Hazard ratio =2.38, 95% confidence interval: 1.31-4.32). Conclusions: The prevalence of MAC was 10.8% in this study. The presence of MAC was associated with a higher rate of concomitant operations, longer hospital stays, and worse survival.

Transcatheter Mitral Valve Replacement Using Transcatheter Aortic Valve or Dedicated Devices: Current Evidence and Future Prospects

Transcatheter mitral valve replacement (TMVR) is a novel and evolving field dedicated to addressing the therapeutic challenges posed by patients at high surgical risk with mitral valve disease. TMVR can be categorized into two distinct fields based on the type of device and its specific indications: TMVR with transcatheter aortic valves (TAV) and TMVR with dedicated devices. Similar to aortic stenosis, TMVR with TAV requires a rigid support structure to secure the valve in place. As a result, it is indicated for patients with failing bioprothesis or surgical rings or mitral valve disease associated with severe mitral annular calcification (MAC), which furnishes the necessary foundation for valve anchoring. While TMVR with TAV has shown promising outcomes in valve-in-valve procedures, its effectiveness remains more contentious in valve-in-ring or valve-in-MAC procedures. Conversely, TMVR with dedicated devices seeks to address native mitral regurgitation, whether accompanied by MAC or not, providing an alternative to Transcatheter Edge-to-Edge Repair (TEER) when TEER is not feasible or expected to yield unsatisfactory results. This emerging field is gradually surmounting technical challenges, including anchoring a valve in a non-calcified annulus and transitioning from the transapical route to the transeptal approach. Numerous devices are presently undergoing clinical trials. This review aims to furnish an overview of the supporting evidence for TMVR using TAV in each specific indication (valve-in-valve, valve-in-ring, valve-in-MAC). Subsequently, we will discuss the anticipated benefits of TMVR with dedicated devices over TEER, summarize the characteristics and clinical results of TMVR systems currently under investigation, and outline future prospects in this field.

Outcomes of mitral valve replacement with complete annular decalcification.

This study aimed to examine the clinical outcomes of mitral valve replacement (MVR) in patients with severe mitral annular calcification (MAC) who required extensive decalcification and mitral annular reconstruction. We reviewed 15 patients with severe MAC who underwent MVR between January 2016 and May 2022. In all cases, the calcified mitral annulus was resected completely using a Cavitron Ultrasound Surgical Aspirator, and a new annulus was created using bovine pericardium. In the acute postoperative phase, strict afterload reduction therapy using an intra-aortic balloon pump (IABP) was administered. The mean age of patients was 73 ± 8 years, and 13 (86.7%) were women. Concomitant aortic valve replacement was performed in 11 (73.3%) patients, tricuspid annuloplasty in 9 (60.0%), coronary artery bypass grafting in 1 (6.7%), and arrhythmia surgery in 7 (46.7%). The mean aortic cross-clamp and cardiopulmonary bypass times were 143 ± 32 min and 175 ± 34 min, respectively. In 13 patients, an IABP was used for 2 or 3 days postoperatively. There were no in-hospital deaths, left ventricular ruptures, or other MAC-related complications. Postoperative echocardiography revealed no paravalvular leakages. Our strategy for managing severe MAC is safe and reproducible even in relatively high-risk patients. Afterload reduction using an IABP in the acute postoperative phase may reduce the risk of fatal complications after extensive decalcification and mitral annular reconstruction.

Hemodynamic implications of mitral annular calcification in patients undergoing transcatheter aortic valve implantation for severe aortic stenosis

PurposesPredicting hemodynamic changes of stenotic mitral valve (MV) lesions with mitral annular calcification (MAC) following transcatheter aortic valve implantation (TAVI) may inform clinical decision-making. This study aimed to investigate the association between the MAC severity quantified by computed tomography (CT) and changes in mean transmitral gradient (mTMG), mitral valve area (MVA) and stroke volume index (SVi) following TAVI.Methods and resultsA total of 708 patients (median age 81, 52% male) with severe aortic stenosis (AS) underwent pre-procedural CT and pre- and post-TAVI transthoracic echocardiography. According to the classification of MAC severity determined by CT, 299 (42.2%) patients had no MAC, 229 (32.3%) mild MAC, 102 (14.4%) moderate MAC, and 78 (11.0%) severe MAC. After adjusting for age and sex, there was no significant change in mTMG following TAVI (Δ mTMG = 0.07 mmHg, 95% CI -0.10 to 0.23, P = 0.92) for patients with no MAC. In contrast, patients with mild MAC (Δ mTMG = 0.21 mmHg, 95% CI 0.01 to 0.40, P = 0.018), moderate MAC (Δ mTMG = 0.31 mmHg, 95% CI 0.02 to 0.60, P = 0.019) and severe MAC (Δ mTMG = 0.43 mmHg, 95% CI 0.10 to 0.76, P = 0.0012) had significant increases in mTMG following TAVI, with greater changes associated with increasing MAC severity. In contrast, there was no significant change in MVA or SVi following TAVI.ConclusionIn patients with severe AS undergoing TAVI, MAC severity was associated with greater increases in post-procedural mTMG whereas MVA or SVi remained unchanged. MAC severity should be considered for potential subsequent MV interventions if TAVI does not improve symptoms.

Double-layer horizontal cross sutures for intra-atrial mitral valve implantation: An effective surgical method for severe mitral annular calcification

ObjectiveSevere mitral annular calcification (MAC) can make prosthetic implantation extremely difficult. Although intra-atrial mitral valve prosthesis implantation without annular decalcification offers a simpler approach, it poses a potential rupture risk due to high left ventricular pressure. We developed a double-layer (DL) horizontal cross-suture technique, which ensures close proximity of the valve prosthesis to the calcified annulus and segregates the left atrial wall from the left ventricle. The aim of this study was to compare the outcomes of DL suture with conventional single-layer (SL) suture in patients with severe MAC. MethodsThis retrospective cohort study consecutively enrolled patients with severe MAC undergoing mitral valve replacement at Beijing Anzhen Hospital from May 2018 to December 2022. A detailed description of the DL suture method is described. Follow-up medical evaluations, including transthoracic echocardiography measurements, were obtained through outpatient chart reviews. ResultsThe study included 10 patients in the DL suture group and 20 in the SL suture group. All patients in the DL group and all but 3 in the SL group achieved technical success. Compared with the SL group, the DL suture technique was associated with lower rates of perivalvular leakage, stroke, new-onset atrial fibrillation, reoperation, and 30-day mortality. Follow-up was complete, with 1 late mortality in the DL group due to stroke and 4 cardiovascular deaths in the SL group. ConclusionsThe DL horizontal cross-suture technique offers a more effective and safer approach for intra-atrial mitral valve implantation in severe MAC cases than the conventional SL suture method.

Treatment of severe mitral annulus calcification: An attractive alternative!

Surgical treatment of mitral valve disease with severe mitral annular calcifications (MACs) is challenging, with reported high morbidity and mortality. Transcatheter treatment options are feasible, however, still far from being optimal alternatives. We report our positive experience with the off-label implant of a BioIntegral Injectable BioPulmonic valve fitted on a circumferential pericardial skirt for the treatment of severe MAC.

5-Year Prospective Evaluation of Mitral Valve-in-Valve, Valve-in-Ring, and Valve-in-MAC Outcomes: MITRAL Trial Final Results

BackgroundThe MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective trial to evaluate the safety and feasibility of balloon-expandable aortic transcatheter heart valves in patients with failed surgical bioprostheses or annuloplasty rings and severe mitral annular calcification treated with mitral valve-in-valve (MViV), valve-in-ring (MViR), or valve–in–mitral annular calcification (ViMAC). ObjectivesThe aim of this study was to evaluate 5-year outcomes among these patients. MethodsA multicenter prospective study was conducted among patients at high surgical risk at 13 U.S. sites. Patients underwent MViV (n = 30), MViR (n = 30), or ViMAC (n = 31) and were followed annually for 5 years. Kansas City Cardiomyopathy Questionnaire scores were obtained at baseline and follow-up visits. Echocardiograms were analyzed at independent core laboratories. ResultsA total of 91 patients underwent transcatheter mitral valve replacement (February 2015 to December 2017). The mean age was 74.3 ± 8.9 years. At 5-year follow-up, the lowest all-cause mortality was observed in the MViV group (21.4%), 94.7% of patients were in NYHA functional class I or II, and the mean mitral gradient was 6.6 ± 2.5 mm Hg. The MViR and ViMAC groups had higher all-cause mortality (65.5% and 67.9%), most survivors were in NYHA functional classes I and II (50% and 55.6%), and mean mitral gradients remained stable (5.8 ± 0.1 and 6.7 ± 2.5 mm Hg). Significant improvements in Kansas City Cardiomyopathy Questionnaire scores were observed when all 3 arms were pooled. ConclusionsMViV, MViR, and ViMAC procedures were associated with sustained improvement of heart failure symptoms and quality of life among survivors at 5 years. Transcatheter heart valve function remained stable in all 3 groups. Patients treated with MViV had excellent survival at 5 years, whereas survival was lower in the MViR and ViMAC groups, consistent with underlying disease severity. Patients with more residual mitral regurgitation had higher mortality.

A Systematic Review and Meta-Analysis of Prevalence, Characteristics, and Impact of Mitral Annular Calcification on Outcomes After Transcatheter Aortic Valve Implantation

There is a paucity of data on the prognostic impact of mitral annular calcification (MAC) in patients who underwent transcatheter aortic valve implantation (TAVI) with conflicting results being reported by the studies that are published. Therefore, we performed a meta-analysis to assess the short-term and long-term outcomes of MAC in patients after TAVI. Of 25,407 studies identified after the initial database search, 4 observational studies comprising 2,620 patients (2,030 patients in the nonsevere MAC arm and 590 patients in the severe MAC arm) were included in the final analysis. Compared with patients with nonsevere MAC, the severe MAC group was associated with significantly higher incidences of overall bleeding (0.75 [0.57 to 0.98], p=0.03, I2=0%) at 30 days. However, no significant difference was observed between the 2 groups for the rest of the 30-day outcomes: all-cause mortality (0.79 [0.42 to 1.48], p=0.46, I2=9%), myocardial infarction (1.62 [0.37 to 7.04], p=0.52, I2=0%), cerebrovascular accident or stroke (1.22 [0.53 to 2.83], p=0.64, I2=0%), acute kidney injury (1.48 [0.64 to 3.42], p=0.35, I2=0%), and pacemaker implantation (0.70 [0.39 to 1.25], p=0.23, I2=68%). Similarly, follow-up outcomes also showed no significant difference between the 2 groups: all-cause mortality (0.69 [0.46 to 1.03], p=0.07, I2=44%), cardiovascular mortality (0.52 [0.24 to 1.13], p=0.10, I2=70%) and stroke (0.83 [0.41 to 1.69], p=0.61, I2=22%). The sensitivity analysis, however, demonstrated significant results for all-cause mortality (0.57 [0.39 to 0.84], p=0.005, I2=7%) by removing the study by Okuno et al5 and cardiovascular mortality (0.41 [0.21 to 0.82], p=0.01, I2=66%) by removing the study by Lak et al.7 In conclusion, our meta-analysis corroborates the notion that isolated MAC is not an independent predictor of long-term mortality after TAVI and determines severe MAC to be a predictor of mortality at follow-up because of the higher incidence of mitral valve dysfunction associated with it.

P219 EXTRINSIC COMPRESSION OF THE RIGHT VENTRICLE CAUSING ISOLATED RIGHT HEART FAILURE

Abstract Isolated right heart failure (RHF) can be caused by right ventricular (RV) compression, mainly described in severe cases of pectus excavatum. Mediastinal masses can determine an extrinsic compression of the RV. A 62–year–old retired agricultural inspector from Sicily presented in our clinic with worsening signs of RHF. His medical history consisted of echinococcosis familiarity, surgically treated congenital subvalvular aortic stenosis, resulted in a residual moderate aortic insufficiency and permanent atrial fibrillation. Around January 2021 he developed isolated leg swelling. Aortic valvular dysfunction, heart failure and other cardiogenic explanations were excluded. A year later dyspnea (NYHA class II) appeared. High resolution CT demonstrated fluid collection with peripheric calcifications inside the anterior mediastinum. PET showed uptake in a limited zone of the anterior mediastinum. The patient slowly started developing ascites, hardly manageable with diuretics because of kidney failure. Transthoracic echocardiography (TTE) highlighted mild RV dysfunction (FAC 35%) and right ventricular free wall hypokinesia due to the mediastinal mass extrinsic compression. Transesophageal echocardiography showed a heterogeneous cystic aspect of the mediastinal mass, an oscillating intraventricular mass of the right aortic cuspid (6x4 mm) and a severe mitral annular calcification. In consideration of medical history, endocarditis was considered. Cardiac magnetic resonance recognized a mediastinal mass with echinococcosis features. Echinococcous serology and antibodies were negative but the Quantiferon tested positive. Laboratory tests showed an absolute eosinophilia and a high CD4/CD8 ratio. Because of the patient severely compromised hemodynamic balance the mass was surgically removed and identified as pseudocystic tuberculoma. After the excision, hemodynamic balance was improved and the TTE showed a restored RV function with persistent hypokinesia of the RV free wall and increased right atrium pressure. In this clinical case RHF was determined by an extracardiac mass which interfered with the hemodynamic balance and the function of the right heart in the absence of any signs of left heart failure. Because of the mass mechanical action on the reduction of RV ejected volumes, a surgical option was the only possible strategy to avoid a following worsening of the heart failure.

Emergent transcatheter mitral valve implantation: Early and mid-term outcomes

BackgroundTranscatheter mitral valve implantation (TMVI) may be attractive to treat high-risk patients with mitral bioprosthesis or annuloplasty ring failure or severe mitral annular calcification. AimTo report the outcomes of patients after valve-in-valve/ring/mitral annular calcification TMVI using balloon expandable transcatheter aortic valves, according to the degree of urgency of the procedure. MethodsAll patients who underwent TMVI in our centre from 2010 to 2021 were classified into three groups: elective, urgent or emergent/salvage TMVI. ResultsA total of 157 patients were included: 129 (82.2%) had elective, 21 (13.4%) urgent and 7 (4.4%) had emergent/salvage TMVI. Patients with emergent/salvage TMVI had a higher EuroSCORE II: elective, 7.3%; urgent, 9.7%; emergent/salvage, 54.5% (P<0.0001). The indication for TMVI was bioprosthesis failure in all of the emergent/salvage group, in 13 of the urgent group (61.9%) and in 62 of the elective group (48.1%). Overall, the technical success rate of TMVI was 86%, and was similar in the three groups (elective, 86.1%; urgent, 95.2%; emergent/salvage, 71.4%). The cumulative survival rate at 2-year follow-up was lower in the emergent/salvage group than in the elective or urgent group (42.9% vs 71.2% for the elective group; 76.2% for the urgent group; log-rank test, P=0.012). The excess mortality in the emergent/salvage group occurred during the first month postprocedure. Thereafter, the 30-day landmark analysis did not show any more statistical difference between the three groups (log-rank test, P=0.94). ConclusionsEmergent/salvage TMVI was associated with high early mortality, but 1-month survivors had similar outcomes to patients with elective/urgent TMVI. The degree of urgency of the procedure should not prevent TMVI in high-risk patients.

D-28 | Mechanism of Mitral Valve Disease and Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Mitral Annular Calcification: A Sub-Analysis of the MITRAL Trial

D-28 | Mechanism of Mitral Valve Disease and Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Mitral Annular Calcification: A Sub-Analysis of the MITRAL Trial

Minimally invasive treatment of mitral valve disease with severe mitral annular calcification: Meeting paper for Mitral Conclave 2022.

Mitral valve disease in presence of severe mitral annular calcification (MAC) remains a challenge for surgeons to address. Conventional surgical techniques have potential for heightened morbidity and mortality. The advent of transcatheter heart valve technology and transcatheter mitral valve replacement (TMVR) holds promise to treat mitral valve disease with MAC with excellent clinical outcomes. We review current treatment strategies for MAC and studies in which TMVR techniques were used. Several studies and a global registry describe outcomes of TMVR for mitral valve disease with MAC. We describe our specific technique on how to perform a minimally invasive transatrial approach for TMVR. TMVR demonstrates strong promise as a safe and effective way to treat mitral valve disease with MAC. We advocate for a minimally invasive transatrial approach when performing TMVR for mitral valve disease with MAC.

Commentary: It is all about the skirt: Length and material

Mitral valve replacement in the setting of severe mitral annular calcification (MAC) remains a surgical challenge. The fundamental concern with mitral valve replacement in the presence of MAC is decalcification required to pass the sutures through the mitral annulus, which can lead to annular disruption or perivalvular leak (PVL). Complex en bloc decalcification and reconstruction of the mitral annulus have been described.1,2 However, these procedures are technically challenging and only done by a few skillful surgeons, and as such they are not ready for widespread use.

Rupture of the Left Ventricle in the Atrioventricular Groove After Mitral Valve Replacement: A Case Report

As we grow older, and our population continues to live longer due to advancements in modern medical therapies, we have a growing population of elderly patients. There will inevitably be more patients who present with mitral stenosis secondary to severe mitral annular calcification and a corresponding need for repair due to the nature of increased friable myocardium present within these tissues. Atrioventricular dissociation associated with left ventricular rupture after mitral valve replacement occurs in approximately 1.2% of cases, and of those cases there is up to a 75% mortality rate even when appropriate surgical techniques are performed [1].

Lithotripsy-Assisted Transcatheter Mitral Valve Replacement for Severe Mitral Annular and Valve Calcification

<h2>Abstract</h2><h3>Background</h3> Transcatheter mitral valve replacement (TMVR) is evolving; however, limitations include severe calcification of the mitral valve leaflets and mitral annular calcification (MAC), which may be associated with incomplete valve expansion. Shockwave intravascular lithotripsy (IVL)–assisted percutaneous mitral valvuloplasty to treat calcific mitral stenosis has been reported. We describe the first human use of IVL-assisted transseptal TMVR with the Intrepid valve to treat a severely calcified mitral valve in a patient with severe stenosis and regurgitation. <h3>Methods</h3> An 83-year-old man with rheumatic heart disease and severe MAC (MAC score, 10; calcium volume score, 7756 cm³) presented with combined mitral stenosis and regurgitation (valve area, 1.5 cm²; 3+ mitral regurgitation [MR]) and medically refractory heart failure symptoms and was enrolled into the APOLLO (Transcatheter Mitral Valve Replacement With the Medtronic Intrepid TMVR System in Patients With Severe Symptomatic Mitral Regurgitation) trial of Intrepid valve TMVR. Transseptal implantation of a 48-mm Intrepid valve was facilitated by Shockwave IVL delivered via two 8.0 × 60–mm M5+ balloons placed across the mitral annulus before implantation. Cerebral embolic protection during IVL and valve implant was provided by a Sentinel device and left subclavian balloon occlusion. <h3>Results</h3> Despite initial postimplant valve frame deformation and moderate central MR, postdilation achieved valve frame expansion and reduced MR. Echocardiography and computed tomography performed before hospital discharge and at 30 days show progressive valve frame expansion in the anteroposterior dimension, increased valve area, and resolution of MR. <h3>Conclusions</h3> Intravascular lithotripsy of severe MAC before self-expanding TMVR may enhance annular compliance, mitigate fibroelastic recoil, and minimize TMVR valve frame deformation. Although promising, further study is required before IVL is considered a routine adjunct for TMVR in severe MAC.