Use of balloon-expandable valves for the surgical treatment of mitral valve disease in the setting of severe mitral annular calcification

Objective: The treatment of mitral valve disease complicated by severe mitral annular calcification poses a significant challenge, with increased risk of morbidity and mortality.We describe the outcomes after surgical mitral valve replacement in patients with severe mitral annular calcification using a balloon-expandable valve.Methods: From 2015 to 2023, 82 consecutive patients received mitral annular calcification using a balloon-expandable valve.No patients were excluded from analysis.Patient records were retrospectively reviewed for baseline characteristics, echocardiography results, intraoperative details, postoperative events, and mortality. Results:The cohort was predominantly female (64.6%; 53/82) with a median age of 76 years [interquartile range, 71-80].Comorbidities including hypertension (92.7%),New York Heart Association class III/IV (59.8%), atrial fibrillation (57.3%), and diabetes (51.2%) were common, contributing to a median Society of Thoracic Surgeons predicted risk of mortality of 5.0% [3.4-8.1].Sixty-eight patients had moderate or greater mitral stenosis, and 42 patients had moderate or greater regurgitation.The median preoperative mean mitral valve gradient was 8.0 [6.0-11.0]mm Hg, which improved to 5.0 [4.0-6.0]mm Hg postoperatively.Paravalvular leak occurred in 3.7% of patients, with trace/trivial in 7.3%.Severe paravalvular leak requiring intervention occurred in 2 patients (2.4%).There were no instances of valve embolization.The incidence of stroke at 30 days was 4.8%.Thirty-day and 1-year mortality were 13.4% and 23.2%, respectively.Conclusions: Surgical implantation of balloon-expandable valve in the setting mitral annular calcification with low rates of significant paravalvular leak and no left ventricular outflow tract obstruction or valve embolization.This technique represents progress in addressing a challenging surgical condition, although further experience and long-term follow-up are needed.(JTCVS Structural and Endovascular 2025;8:100083) Preoperative imaging with virtual valve and neo-LVOT with ensuing postoperative imaging. CENTRAL MESSAGEIn the setting of severe MAC, preventing traditional MV intervention, BEV-in-MAC is an effective approach for treatment of MVD in our experience. PERSPECTIVEPatients with MVD and severe MAC may be deemed inoperable for traditional surgical treatment.In these patients, we describe the successful treatment using placement of a BEV with good operative outcomes in this inherently very high-risk cohort.