Endoscopic mitral valve replacement in extensive mitral annular calcification with a posterior pericardial patch

Extensive mitral annular calcification represents a major technical challenge in mitral valve surgery and is associated with increased operative mortality and morbidity, including atrioventricular disruption, circumflex artery injury and prosthetic valve dehiscence. Management strategies remain controversial, including in patients suitable for transcatheter interventions. We present a case of severe symptomatic mitral regurgitation in an elderly female patient with extensive circumferential mitral annular calcification. Preoperative imaging confirmed severe mitral regurgitation with restricted calcified mitral leaflets and preserved left ventricular systolic function. Transcatheter mitral valve implantation was considered, but deemed unsuitable because of annular size. The patient therefore underwent endoscopic mitral valve replacement through a right minithoracotomy using femoro-femoral cardiopulmonary bypass. An endoaortic balloon was used to arrest the heart with cardioplegia. After excision of the native valve and limited debridement of calcification, a bioprosthetic mitral valve was implanted and tied with pledgeted braided sutures and an automatic suture knotting device (CorKnot). A bovine pericardial patch was sutured to the posterior portion of the prosthetic sewing ring using a posterior skirt technique to reinforce the posterior annulus and reduce paravalvular leakage risk. Postoperative echocardiography demonstrated a well-functioning prosthetic valve with preserved ventricular function and a trivial paravalvular leak.