Commentary: Enhanced open transcatheter mitral valve replacement: The ultimate hybrid approach
Bibliographic record
Abstract
Central MessageHybrid mitral valve replacement performed by surgical teams with expertise in both open and transcatheter approaches should improve the management of technically complex disease.See Article page 25. Hybrid mitral valve replacement performed by surgical teams with expertise in both open and transcatheter approaches should improve the management of technically complex disease. See Article page 25. In symptomatic mitral valve disease with severe mitral annular calcification (MAC), mitral valve replacement is challenging, and decalcification carries a risk of serious injury to the atrioventricular groove, especially in elderly patients. In such situations, an open-heart deployment of a balloon-expandable aortic prosthesis was proposed as a safer alternative to avoid a potentially hazardous decalcification. However, this technique may have several disadvantages, including the risk of periprosthetic leakage or obstruction of the left ventricular outflow tract (LVOT). Consideration of surgical techniques to overcome these limitations is essential. Codecasa and colleagues1Codecasa R. De Cillis P. Stefàno P. Balloon-expandable prosthesis for open mitral replacement with a calcified mitral annulus.J Thorac Cardiovasc Surg Tech. 2021; 5: 25-26Google Scholar report their elegant management of a 74-year-old woman with rheumatic mitral valve disease, with severe MAC on preoperative chest computed tomography scan. They performed an open mitral implantation of a balloon-expandable aortic prosthesis, preoperatively sized to allow for slight oversizing and minimal stress to the atrioventricular groove. The anterior mitral valve leaflet was resected, and a bovine pericardial skirt was sutured to the base of the prosthesis and to the mitral annulus to prevent periprosthetic leaks. A septal myectomy was also performed to prevent obstruction of the LVOT. Apart from temporary atrioventricular block requiring external pacing, the postoperative course was uneventful and the patient was discharged 9 days after the operation. Although conventional mitral valve surgery with MAC can be performed with good results in acceptable-risk patients, severe circumferential MAC frequently presents in elderly patients and is associated with increased operative risk.2Saran N. Greason K.L. Schaff H.V. Cicek S.M. Daly R.C. Maltais S. et al.Does mitral valve calcium in patients undergoing mitral valve replacement portend worse survival?.Ann Thorac Surg. 2019; 107: 444-452Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Transcatheter techniques involving the deployment of an aortic balloon-expandable prosthesis for native mitral valve disease have drawbacks such as LVOT obstruction or periprosthetic regurgitation and have led to disappointing results in patients with MAC.3Kiefer P. Noack T. Seeburger J. Hoyer A. Linke A. Mangner N. et al.Transapical mitral valve implantation for native mitral valve stenosis using a balloon-expandable prosthesis.Ann Thorac Surg. 2017; 104: 2030-2036Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Initially described in case reports as either a planned procedure or an intraoperative bailout maneuver, the alternative hybrid approach has been demonstrated to be a feasible and hemodynamically effective solution for severe MAC. The open hybrid approach allows for resection of the anterior mitral valve leaflet and septal myectomy, which theoretically should maximize the postoperative neo-LVOT diameter.4Russell H.M. Guerrero M.E. Salinger M.H. Manzuk M.A. Pursnani A.K. Wang D. et al.Open atrial transcatheter mitral valve replacement in patients with mitral annular calcification.J Am Coll Cardiol. 2018; 72: 1437-1448Crossref PubMed Scopus (48) Google Scholar Nevertheless, further studies are mandatory to determine whether the long-term outcome for this technique is as promising as its short-term results. The report by Codecasa and colleagues1Codecasa R. De Cillis P. Stefàno P. Balloon-expandable prosthesis for open mitral replacement with a calcified mitral annulus.J Thorac Cardiovasc Surg Tech. 2021; 5: 25-26Google Scholar illustrates the pivotal role of a multidisciplinary management of such patients, including heart team discussion, multimodality imaging (echocardiography and computed tomography scan), and rigorous preoperative planning (eg, prosthetic valve sizing and software for neo-LVOT determination). There is little doubt as to the beneficial influence of surgeons with expertise in both surgical and transcatheter approaches for these complex patients. Balloon-expandable prosthesis for open mitral replacement with a calcified mitral annulusJTCVS TechniquesVol. 5PreviewIn presence of a heavily calcified mitral apparatus, mitral valve replacement may represent a challenging surgical intervention. The risk of injury to the atrioventricular groove is high and the success rate of its consequent repair is very low. Nevertheless, a symptomatic patient affected by severe mitral stenosis, especially when balloon commissurotomy is not indicated, should not be left untreated. Mitral decalcification represents a risky option, but an apparently simpler and safer solution can be an open-heart positioning of an inverted aortic balloon-expandable aortic prosthesis. Full-Text PDF Open Access
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.007 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.001 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".