Accepted Manuscript. MAC: Mitral Annular Calcification or a Modern Approach to Concept learning in surgery

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1 Accepted Manuscript MAC: Mitral Annular Calcification or a Modern Approach to Concept learning in surgery Serge Kobsa, MD, PhD, Hiroo Takayama, MD, PhD PII: S (18) DOI: /j.jtcvs Reference: YMTC To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: 15 June 2018 Revised Date: 15 June 2018 Accepted Date: 18 June 2018 Please cite this article as: Kobsa S, Takayama H, MAC: Mitral Annular Calcification or a Modern Approach to Concept learning in surgery, The Journal of Thoracic and Cardiovascular Surgery (2018), doi: /j.jtcvs This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 Title: MAC: Mitral Annular Calcification or a Modern Approach to Concept learning in surgery Authors: Serge Kobsa, MD, PhD, and Hiroo Takayama, MD, PhD Author affiliation: Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY Corresponding Author: Hiroo Takayama, MD, PhD, Associate Professor of Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Columbia University Medical Center, Milstein Hospital, 7GN-435, 177 Fort Washington Ave, New York, NY 10032, USA, Phone: , ht2225@cumc.columbia.edu Editorial on: Current and evolving strategies in the management of severe mitral annular calcification by Bedeir at al. Word count: 496

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4 Title: MAC: Mitral Annular Calcification - a Modern Approach to Concept learning in surgery Authors: Serge Kobsa, MD, PhD, and Hiroo Takayama, MD, PhD Author affiliation: Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY Corresponding Author: Hiroo Takayama, MD, PhD, Associate Professor of Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Columbia University Medical Center, Milstein Hospital, 7GN-435, 177 Fort Washington Ave, New York, NY 10032, USA, Phone: , ht2225@cumc.columbia.edu Editorial on: Current and evolving strategies in the management of severe mitral annular calcification by Bedeir at al. Word count: 496

5 Central Message: The referred article provides an excellent review of knowledge and surgical tips on severe mitral annular calcification (MAC). It is also notable in that it introduced a modern approach to concept (MAC) learning in surgery. Central Picture: Twitter accounts of AATS (@AATSHQ), JTCVS (@AATSJournal), and the authors.

6 In this issue of the Journal, Bedeir and colleagues offer a thoughtful and thorough review of one of the more daunting issues faced by cardiac surgeons: how to deal with severe mitral annular calcification (MAC). Successful surgical management of severe MAC has been described involving the spectrum of approaches ranging from no annular debridement 1, conservative decalcification 2, to aggressive debridement and complete reconstruction of the mitral anulus 3,4. While several prior reviews offer discussion of pathophysiology, medical management and established open surgical techniques for management of MAC, the authors synthesize available knowledge and build upon it by discussing an emerging and potentially game-changing technique - the use of expandable transcatheter heart valves (THVs). While total percutaneous approach requires further accumulation of clinical experience and data, practical surgical interest in 2018 may be in the hybrid approach involving transatrial deployment of THVs under direct vision during a sternotomy. This procedure significantly facilitates this otherwise complicated operation 5 7, since it does not require extensive decalcification and debridement of the annulus, while allowing the surgeon to maintain the control for precise sizing, positioning and evaluation of the valve anchoring. In addition, there is an opportunity for placement of a felt skirt and pledgetted sutures to reduce PVL and partially anchor the valve, as well as for resection of the anterior mitral valve leaflet, and even septal myectomy, thus allowing for safe treatment of patients at high risk for LVOT obstruction or valve embolization. Beyond the surgical concepts discussed, the article is also notable for the unique and innovative ways in which it introduces video references. We were impressed and encourage the readers to view them on YouTube and the AATS website. They provide excellent and very interesting learning opportunities for surgeons and are the epitomization of seeing is believing. We also invite the readers to visit the video of our case, referenced in this editorial 8. This form of reference allowes the use of this long video, which shows more conservative approaches, including minimal debridement, needle placement through or

7 around the MAC with needle placement in deep LV muscle, and the use of a small biological valve, as well as, perhaps more importantly, our struggle during the procedure. Technology now allows anyone to gain easy and free access to information regarding highly specific topics. While this can enhance, improve and might even transform the surgical education and learning, some of the recent events have highlighted the dangers of easy exposure of the public to controversial information from uncertain sources. For instance, while the cited video references in this article appear to be high quality materials created by highly qualified people, their scientific quality and qualification might need to be considered differently from conventional peer-reviewed published materials. For all of these reasons, we feel that the role of the professional societies and journals as reliable and trustworthy sources will only become more important, and it is a pleasure to know that AATS (@AATSHQ) and JTCVS (@AATSJournals) already have a social media ( SoMe ) presence!

8 REFERENCES 1. Salhiyyah K, Kattach H, Ashoub A, et al. Mitral valve replacement in severely calcified mitral valve annulus: a 10-year experience. Eur J Cardio-Thoracic Surg doi: /ejcts/ezx Ben-Avi R, Orlov B, Sternik L, et al. Short- and long-term results after prosthetic mitral valve implantation in patients with severe mitral annulus calcification. Interact Cardiovasc Thorac Surg doi: /icvts/ivx David TE, Feindel CM, Armstrong S, Sun Z. Reconstruction of the mitral anulus. A ten-year experience. J Thorac Cardiovasc Surg doi: /s (95) Carpentier AF, Pellerin M, Fuzellier JF, et al. Extensive calcification of the mitral valve anulus: Pathology and surgical management. J Thorac Cardiovasc Surg doi: /s (96)70332-x. 5. Praz F, Khalique OK, Lee R, et al. Transatrial implantation of a transcatheter heart valve for severe mitral annular calcification. J Thorac Cardiovasc Surg doi: 6. Guerrero M, Urena M, Himbert D, et al. 1-Year Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Mitral Annular Calcification. J Am Coll Cardiol. 2018;71(17): doi: /j.jacc El Sabbagh A, Eleid MF, Foley TA, et al. Direct transatrial implantation of balloon-expandable valve for mitral stenosis with severe annular calcifica ons: early experience and lessons learned. Eur J Cardio-Thoracic Surg. 2018;53(1): doi: /ejcts/ezx

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