Pushing the hybrid approach to the edges, three stories in one: a case report

Mitral annular calcification (MAC) is common in the elderly. Extensive calcification is historically challenging for the cardiac surgeons, with traditional surgical approaches carrying significant risks. Less invasive approaches have recently been explored in an attempt to reduce this risk. We report the case of a 75-year-old woman who presented with recurrent pulmonary oedema, due to severe MAC and mitral regurgitation. Her past medical history included bioprosthetic aortic valve replacement five years ago. Given the extensive MAC and the patient’s frailty, a minimally invasive hybrid approach with direct implantation of a transcatheter balloon expandable Sapien 3 valve was selected to manage the patient. Although the post-surgical result was initially excellent with elimination of the mitral regurgitation, the patient’s postoperative course was marked by two serious complications, namely acute severe aortic regurgitation due to rupture of the bioprosthetic valve’s right cusp, as well as severe paravalvular leak of the Sapien valve, due to posterior migration towards the left atrium. These were managed successfully with emergency valve-in-valve implantation using the ‘’Double Chimney’’ technique for the bioprosthetic aortic valve, as well as transeptal valve-in-valve implantation of a second Sapien valve in the mitral valve, which sealed the gap between the first Sapien and the calcified mitral annulus. This case illustrates a less invasive approach for the management of severe MAC. Complications can still occur in this high-risk group of patients and therefore, such cases should be managed with close collaboration between cardiac surgeons and cardiologists, in centres with high expertise.