Intentional Percutaneous Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction During Transcatheter Mitral Valve Replacement First-in-Human Experience

• Authors: Vasilis Babaliaros, Emory University; Adam B. Greenbaum, Henry Ford Health System; Jaffar Khan, Emory University; Toby Rogers, National Heart Lung and Blood Institute; Dee Dee Wang, Henry Ford Health System; Marvin H. Eng, Henry Ford Health System; William W. O'Neill, Henry Ford Health System; Gaetano Paone, Henry Ford Health System; Stamatios Lerakis, Emory University; Vinod Thourani, Emory University; Dennis Kim, Emory University; Marcus Y. Chen, National Heart Lung and Blood Institute; Robert J. Lederman, National Heart Lung and Blood Institute
• Journal Title: JACC: Cardiovascular Interventions
• Volume: Volume 10, Number 8
• Publisher: Elsevier | 2017-04-24, Pages 798-809
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.jcin.2017.01.035
• Subjects: Health Sciences, Medicine and Surgery
• Keywords: Science & Technology; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems; Cardiovascular System & Cardiology; left ventricular outflow tract obstruction; mitral valve; structural heart disease; transcatheter mitral valve replacement; valvular heart disease; PREDICTING LVOT OBSTRUCTION; ALCOHOL SEPTAL ABLATION; TRACT OBSTRUCTION; ANNULAR CALCIFICATION; AORTIC-STENOSIS; SAPIEN XT; IN-VALVE; IMPLANTATION; RADIOFREQUENCY; ACCESS

Abstract

Objectives: This study sought to use a new catheter technique to split the anterior mitral valve leaflet (AML) and prevent iatrogenic left ventricular outflow tract (LVOT) obstruction immediately before transcatheter mitral valve replacement (TMVR). Background: LVOT obstruction is a life-threatening complication of TMVR, caused by septal displacement of the AML. Methods: The procedure was used in patients with severe mitral valve disease and prohibitive surgical risk. Patients either had prior surgical mitral valve ring (n = 3) or band annuloplasty (n = 1) or mitral annular calcification with stenosis (n = 1). Iatrogenic LVOT obstruction or transcatheter heart valve dysfunction was predicted in all based on echocardiography and computed tomography. Transfemoral coronary guiding catheters directed an electrified guidewire across the center and base of the AML toward a snare in the left atrium. The externalized guidewire loop was then electrified to lacerate the AML along the centerline from base to tip, sparing chordae, immediately before transseptal TMVR. Results: Five patients with prohibitive risk of LVOT obstruction or transcatheter heart valve dysfunction from TMVR successfully underwent LAMPOON, with longitudinal splitting of the A2 scallop of the AML, before valve implantation. Multiplane computed tomography modeling predicted hemodynamic collapse from TMVR assuming an intact AML. However, critical LVOT gradients were not seen following LAMPOON and TMVR. Doppler blood flow was seen across transcatheter heart valve struts that encroached the LVOT, because the AML was split. Transcatheter heart valve function was unimpeded. Conclusions: This novel catheter technique, which resembles surgical chord-sparing AML resection, may enable TMVR in patients with prohibitive risk of LVOT obstruction or transcatheter heart valve dysfunction.