BACKGROUND: Coronary accessibility following redo–transcatheter aortic valve replacement (redo-TAVR) is increasingly important, particularly in younger low-risk patients. This study aimed to predict coronary accessibility after simulated Sapien-3 balloon-expandable valve implantation within an Evolut supra-annular, self-expanding valve using pre-TAVR computed tomography (CT) imaging. METHODS: A total of 219 pre-TAVR CT scans from the Evolut Low-Risk CT substudy were analyzed. Virtual Evolut and Sapien-3 valves were sized using CT-based diameters. Two initial Evolut implant depths were analyzed, 3 and 5 mm. Coronary accessibility was evaluated for 2 Sapien-3 in Evolut implant positions: Sapien-3 outflow at Evolut node 4 and Evolut node 5. RESULTS: With a 3-mm initial Evolut implant depth, suitable coronary access was predicted in 84% of patients with the Sapien-3 outflow at Evolut node 4, and in 31% of cases with the Sapien-3 outflow at Evolut node 5 (P<0.001). Coronary accessibility improved with a 5-mm Evolut implant depth: 97% at node 4 and 65% at node 5 (P<0.001). When comparing 3- to 5-mm Evolut implant depth, sinus sequestration was the lowest with Sapien-3 outflow at Evolut node 4 (13% versus 2%; P<0.001), and the highest at Evolut node 5 (61% versus 32%; P<0.001). CONCLUSIONS: Coronary accessibility after Sapien-3 in Evolut redo-TAVR relates to the initial Evolut implant depth, the Sapien-3 outflow position within the Evolut, and the native annular anatomy. This CT-based quantitative analysis may provide useful information to inform and refine individualized preprocedural CT planning of the initial TAVR and guide lifetime management for future coronary access after redo-TAVR.

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.

Our patient was a 50-year-old woman with tricuspid atresia who had undergone palliation with a Potts shunt to the left pulmonary artery as an infant and a classic Glenn shunt to the right pulmonary artery as a young child. Under general anesthesia, she underwent transcatheter edge-to-edge repair of the mitral valve for severe symptomatic mitral regurgitation. (Level of Difficulty: Advanced.)

Background: Left ventricular outflow tract (LVOT) obstruction is a leading cause of mortality and exclusion from transcatheter mitral valve replacement (TMVR). Intentional laceration of the anterior mitral valve leaflet to prevent LVOT obstruction (LAMPOON) is a transcatheter mimic of surgical chord-sparing leaflet resection. Objectives: The purpose of this prospective multicenter trial was to study LAMPOON with transseptal (Edwards Lifesciences, Irvine, California) TMVR in annuloplasty rings or native mitral annular calcification (MAC). Methods: Subjects at high or extreme surgical risk and prohibitive risk of LVOT obstruction from TMVR were included. Eligibility was modified midtrial to exclude subjects with threatened LVOT obstruction from a Sapien 3 valve fabric skirt. The primary endpoint was procedure survival with successful LAMPOON, with successful TMVR, without reintervention, and with LVOT gradient <30 mm Hg (“optimal”) or <50 mm Hg (“acceptable”). Secondary endpoints included 30-day mortality and major adverse cardiovascular events. There was universal source-data verification and independent monitoring. All endpoints were independently adjudicated. Central laboratories analyzed echocardiogram and CT images. Results: Between June 2017 and June 2018, 30 subjects were enrolled equally between the MAC and ring arms. LAMPOON traversal and midline laceration was successful in 100%. Procedure survival was 100%, and 30-day survival was 93%. Primary success was achieved in 73%, driven by additional procedures for paravalvular leak (10%) and high-skirt neo-LVOT gradients observed before a protocol amendment. There were no strokes. Conclusions: LAMPOON was feasible in native and annuloplasty ring anatomies in patients who were otherwise ineligible for treatment, with acceptable safety. LAMPOON was effective in preventing LVOT obstruction from TMVR. Despite LAMPOON, TMVR using Sapien 3 in annuloplasty rings and MAC still exhibits important limitations. (NHLBI DIR LAMPOON Study: Intentional Laceration of the Anterior Mitral Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Implantation; NCT03015194)

Ischemic septal rupture producing an acquired ventricular septal defect (VSD) is a catastrophic complication of acute myocardial infarction. Acute therapeutic options are often futile because the tear in the septum is complex with surrounding edematous and necrotic tissue that evolves over several weeks following infarction. Concomitant left ventricular (LV) and/or right ventricular (RV) dysfunction limit effective surgical repair mostly to survivors of natural selection. “Dedicated” endovascular devices are best suited for the minority of patients with thin septums and small, circular defects during the chronic phase of post-infarct VSD1. In other VSD anatomies, commercially available devices are too rigid to deliver, have an outward force that expands already necrotic defects and are highly permeable, failing to occlude high-flow defects. There is a need for better therapy.

Patients with severe symptomatic tricuspid regurgitation face a significant dilemma in treatment options, as the yearly mortality with medical therapy and the surgical mortality for tricuspid repair or replacement are high. Transcatheter edge-to-edge repair (TEER) for the tricuspid valve is becoming a viable option in patients, although procedural success is dependent on high-quality imaging. While transesophageal echocardiography remains the standard for tricuspid TEER procedures, intracardiac echocardiography (ICE) with three-dimensional (3D) multiplanar reconstruction (MPR) has many theoretical and practical advantages. The aim of this article was to describe the in vitro wet lab–based imaging work done to facilitate the best approach to 3D MPR ICE imaging and the procedural experience gained with 3D MPR ICE in tricuspid TEER procedures with the PASCAL device.

Transcatheter mitral valve replacement (TMVR) risks left ventricular outflow tract (LVOT) obstruction from permanent displacement of the anterior leaflet and/or the implant itself in cases of hypertrophied ventricles1,2. While LAMPOON mitigates the risk associated with displacement of the anterior mitral leaflet3, obstruction from the TMVR is often addressed with ventricular septal reduction. Ablation with either alcohol or radiofrequency risks geographic miss, inadequate debulking, and complete heart block. It also requires time-dependent myocardial necrosis, which delays therapeutic TMVR. We developed a novel transcatheter electrosurgical myotomy mimicking classic surgical myectomy to overcome these limitations4. Herein we report the first SESAME (Septal Scoring Along Midline Endocardium) procedure to treat hypertrophic cardiomyopathy and allow TMVR.

Transcatheter mitral valve replacement (TMVR) using the SAPIEN platform has been performed in failed bioprosthetic valves (valve-in-valve), surgical annuloplasty rings (valve-in-ring), and native valves with mitral annular calcification (MAC) (valve-in-MAC). Experience over the past decade has identified important challenges and solutions to improve clinical outcomes. In this review, we discuss the indication, trend in utilization, unique challenges, procedural planning, and clinical outcomes of valve-in-valve, valve-in-ring, and valve-in-MAC TMVR.

There are few satisfactory options to treat residual or recurrent mitral regurgitation (MR) with or without concomitant mitral stenosis following transcatheter edge-to-edge repair (TEER) (1). Electrosurgical laceration and stabilization of failed MitraClip[s] (Abbott) (ELASTA-Clip) by electrosurgical detachment of clip(s) from the anterior leaflet, enables transcatheter mitral valve replacement (TMVR) (2). To date ELASTA-Clip has been reported only with hybrid surgical transapical Tendyne valve implantation (Abbott). Tendyne/ELASTA-clip is often technically successful but clinically disappointing in part, we hypothesize, because of the morbidity of surgical transapical access with adverse periprocedural events and prolonged recovery (3). Herein, we describe a fully percutaneous ELASTA-Clip using an investigational M3 Valve (Edwards).

Coronary obstruction remains a pernicious complication of transcatheter aortic valve replacement (TAVR). It is caused by outward displacement of a valve leaflet, directly blocking the coronary ostium or sealing the coronary sinus. Bioprosthetic or native aortic leaflet intentional laceration to prevent coronary artery obstruction (BASILICA) creates a slit lesion along the midline of the aortic leaflet, which splays after TAVR, allowing coronary perfusion. Despite successful BASILICA, a small fraction of patients experience some degree of obstruction, such as from a prolapsing leaflet. We developed a leaflet removal technique (CATHeter Electrosurgical Debulking and RemovAL [CATHEDRAL]; Video 1) to treat such patients and herein report the first application.