Transatrial Balloon-Expandable Valve Implantation for Severe Mitral Annular Calcification with Native Leaflet Sealing

Authors

• Omar Saleh, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
• Rishab Agarwal, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
• Israa Saleh, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
• Nicholas Valle, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
• Joshua Dolsen, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
• Raymond L. Benza, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
• Deepak R. Talreja, Sentara Medical Group
• Clinton D. Kemp, Sentara Medical Group
• Matthew R. Summers, Sentara Medical Group
• Christopher M. Sciortino, Sentara Health

ORCID

0009-0007-8448-9999 (Agarwal), 0009-0000-8820-2050 (Valle), 0009-0005-5173-0200 (Dolsen), 0000-0001-9627-6236 (Benza)

Document Type

Article

Publication Date

2026

DOI

10.1016/j.jaccas.2026.109022

Publication Title

JACC: Case Reports

Volume

Advance online publication

Pages

9 pp.

Abstract

Background: Severe mitral annular calcification (MAC) limits mitral intervention options. Transseptal valve-in-MAC (ViMAC) transcatheter mitral valve replacement (TMVR) risks neo-left ventricular outflow tract (neo-LVOT) obstruction and paravalvular leak, while surgical replacement requires extensive annular reconstruction.

Case Summary: We report 3 high-risk patients with severe MAC (computed tomography [CT]-based MAC scores 7-10) who underwent open transatrial valve-in-MAC TMVR via a balloon-expandable valve after CT-based simulation and multidisciplinary heart review identified increased risk of valve malapposition or neo-LVOT obstruction precluding transseptal approach. Native anterior mitral leaflet tissue was preserved, everted, and fixed to the bioprosthetic valve cuff, creating a seal to address frame-annulus gaps.

Discussion: All patients achieved stable prosthesis apposition with no paravalvular leak, stable LVOT gradients, and significantly improved functional status at their 3-month follow-up. Two underwent concomitant aortic root replacement; one underwent concomitant septal myectomy and tricuspid repair.

Take-Home Messages: CT-based simulation facilitates identification of patients who face increased risk of complications with transseptal TMVR. This series demonstrates reproducibility of native anterior mitral leaflet fixation to address frame-annulus gaps in transcatheter mitral replacement.

Rights

© 2026 The Authors.

This is an open access article under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY-NC-ND 4.0) International License.

Original Publication Citation

Saleh, O., Agarwal, R., Saleh, I., Valle, N., Dolsen, J., Benza, R. L., Talreja, D. R., Kemp, C. D., Summers, M. R., & Sciortino, C. M. (2026). Transatrial balloon-expandable valve implantation for severe mitral annular calcification with native leaflet sealing. JACC: Case Reports. Advance online publication. https://doi.org/10.1016/j.jaccas.2026.109022

Repository Citation

Saleh, O., Agarwal, R., Saleh, I., Valle, N., Dolsen, J., Benza, R. L., Talreja, D. R., Kemp, C. D., Summers, M. R., & Sciortino, C. M. (2026). Transatrial balloon-expandable valve implantation for severe mitral annular calcification with native leaflet sealing. JACC: Case Reports. Advance online publication. https://doi.org/10.1016/j.jaccas.2026.109022