Abstract
BACKGROUND: Mitral annular calcification (MAC) is progressive degenerative calcification of the mitral valve that frequently results in mitral stenosis, mitral regurgitation, or both. Off-label transcatheter mitral valve replacement is the most common treatment in high to prohibitive surgical risk patients. Large mitral annular dimensions with risk of valve migration or paravalvular leak (PVL) remain a challenge. CASE PRESENTATION: We describe a case of a prohibitive surgical risk patient with multiple comorbidities who presented with heart failure symptoms. A transesophageal echocardiogram confirmed severe mitral valve stenosis and regurgitation in the setting of severe MAC, whereas computed tomography angiography showed large annular dimensions. Given these dimensions, there was significant concern for valve migration or PVL. DISCUSSION: We describe for the first time using a covered stent with occluder in the valve commissure to reduce the mitral valve annular area and facilitate a successful transcatheter mitral valve-in-MAC procedure in patients with a large mitral valve annulus. TAKE-HOME MESSAGES: Transcatheter mitral valve replacement using a balloon expandable valve in a large mitral valve annulus could be challenging because of concern for valve migration, embolization, or PVL. A covered stent with an occluder in the native valve commissure could help reduce the mitral valve annular dimensions and provide an additional anchor point for the transcatheter valve.