Overcoming a Surgical Challenge: Inverted Aortic Prosthetic Valves in Small Mitral Annulus

Abstract

Congratulations to Dr Shalabi and colleagues [1] for this valuable study. This was an interesting comparison with a good number of patients. We have some considerations about some issues regarding this study. Different types of valves with different generic names obviously have different orifice diameters and orifice areas. We believe that this situation requires that these data should have been supplemented by the manufacturers and included in the text instead of just stating that a valve was a 19-or 21-mm sutured bioprosthesis. The Perceval sutureless valve (LivaNova, London, United Kingdom) has a metallic fixation stent to prevent migration and oscillation. This segment possesses a higher-profile metallic load compressing the aortic wall, unlike the other types of bioprosthetic valves. This feature may create some lesions on the aortic wall. Finally, the Perceval system is very similar to that used in transcatheter aortic valve implantation. Could the authors mention why they used surgical sutureless valve implantation instead of transcatheter aortic valve implantation?

Early and Mid-Term Outcomes of Using the Chimney Technique in Redo Mitral Valve Replacement in Patients with a Small Mitral Annulus

“…The small mitral annulus may be the result of extensive calcification of the mitral annulus to the leaflets, small patient size, or previous mitral repair with a small annular ring. Surgical alternatives for Re-MVR patients with a small mitral annulus, such as extensive annular debridement and reconstruction, positioning a prosthesis in a supra-annular intra-atrial location, or deploying a transcatheter aortic prosthesis in the mitral position, are constrained and pose technical challenges [ 3 , 5 , 7 ]. Of course, there are few reports of enlarging the mitral annulus and such procedures carry a nontrivial risk of heart block.…”

“…Performing mitral valve replacement (MVR) in patients with a small mitral annulus (<25 mm diameter) is challenging from a technical standpoint and is associated with a higher risk of unfavorable prognosis, thereby offering limited alternatives for these individuals [ 1 , 2 , 3 , 4 , 5 ]. Obviously, surgery is very difficult in patients with small mitral valve Re-MVR and involves a substantial risk of mitral annular disruption, perivalvular leak, ventricular dysfunction, and even ventricular rupture [ 6 , 7 , 8 , 9 , 10 ].…”

“…Prosthesis-patient mismatch (PPM) arises when there is a disparity between the effective orifice area (EOA) of the prosthetic valve and the necessary cardiac output to meet the demands of the patient’s body surface area (BSA) [ 2 ]. Undoubtedly, performing routine MVR in patients with a small mitral annulus without annular enlargement invariably leads to the postoperative occurrence of PPM [ 3 ]. The chimney technique was initially employed to address PPM in pediatric patients undergoing MVR [ 11 ].…”

Early and Mid-Term Outcomes of Using the Chimney Technology in Redo-Mitral Valve Replacement in Patients with Small Mitral Annulus

“…The small mitral annulus may be the result of extensive calcification of the mitral annulus to the leaflets, small patient size, or previous mitral repair with a small annular ring5. Surgical options including extensive annular debridement and reconstruction, placement of prosthesis in a supra-annular intra-atrial position, or placement of a transcatheter aortic prosthesis in the mitral position are limited and technically challenging for redo-MVR patients with a small mitral annulus [3,5,7]. All of these techniques are associated with an increased risk of disruption of the ventriculoatrial and mitral annulus, ventricular dysfunction, perivalvular leakage, or LVOTO.…”

“…Mitral valve replacement (MVR) in patients with small mitral annulus (<25 mm diameter) is technically difficult and carries an increased risk of poor prognosis, which results in very limited options for those [1][2][3][4][5]. Obviously, surgery is very difficult in patients with small mitral valve redo-MVR and involves a substantial risk of mitral annular disruption, ventricular dysfunction, or perivalvular leak [6][7][8][9][10].…”