Prevention and Treatment of Left Ventricular Outflow Tract Obstruction After Transcatheter Mitral Valve Replacement

• Type of Material: Article
• Authors: John Cyril Lisko, Emory University; Norihiko Kamioka, Emory University; Patrick Thomas Gleason, Emory University; Isida Byku, Emory University; Lucia Alvarez, Emory University; Jaffar M. Khan, Washington Hospital Center; Toby Rogers, National Institutes of Health; Robert Lederman, National Institutes of Health; Adam B. Greenbaum, Emory University; Vasilis Babaliaros, Emory University
• Language: English
• Date: 2019-07
• Publisher: Elsevier
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2019 Elsevier Inc. All rights reserved.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): https://doi.org/10.1016/j.iccl.2019.02.005
• Title of Journal or Parent Work: Interventional Cardiology Clinics
• Volume: 8
• Issue: 3
• Start Page: 279
• End Page: 285
• Keywords: computed tomography; left ventricular outflow tract; transcatheter mitral valve replacement
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

An 84-year-old Caucasian woman with a past medical history significant for coronary artery disease status post 3 vessel coronary artery bypass grafting, mitral valve repair with a mitral ring, chronic kidney disease stage IV, chronic obstructive pulmonary disease not on home oxygen, and insulin-dependent diabetes presents to the Structural Heart and Valve clinic with a chief complaint of worsening shortness of breath. An echocardiogram reveals severe mitral regurgitation (regurgitant fraction, 45%, effective regurgitant orifice [ERO], 0.46 mm2), mean gradient, 3 mm Hg). Her Society of Thoracic Surgery predicted operative mortality risk score calculates to 9.4%. The heart team deems her to be a candidate for a valve-in-ring transcatheter mitral valve replacement (TMVR); however, her preprocedural planning computed tomography (CT) scan demonstrates a thickened interventricular septum and concern for left ventricular outflow tract (LVOT) obstruction. TMVR is becoming a viable option for patients with severe mitral valve disease and no surgical options.1 LVOT obstruction is a known complication of TMVR that portends a poor prognosis.2 This review discusses the current state of TMVR and reviews strategies to prevent LVOT obstruction, with an emphasis on Heart Team decision-making and promising prophylactic, electrosurgical techniques to modify the mitral valve leaflets before valve implantation.