TCT-861 Predicting Left Ventricular Outflow Tract Obstruction from Transcatheter Mitral Valve Replacement Despite Anterior Mitral Leaflet Resection: the Skirt NeoLVOT

Given the prevalence of mitral valve pathology in high-risk patients, transcatheter mitral valve replacement (TMVR) is becoming an attractive treatment modality. A known complication of TMVR is left ventricular outflow tract obstruction (LVOT) due to the prosthetic mitral valve and native anterior mitral valve leaflet encroaching into the LVOT. This is a serious complication which can lead to decreased cardiac output and death. Preprocedural planning with various imaging modalities (multi-detector cardiac CT and echocardiography) can predict those at high risk of LVOT obstruct. To increase awareness and to prevent this complication from occurring in the future, we present a case of LVOT obstruction after TMVR.

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Antegrade Intentional Laceration of the Anterior Mitral Leaflet to Prevent Left Ventricular Outflow Tract Obstruction

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.119.008903 ◽

2020 ◽

Vol 13 (6) ◽

Author(s):

John C. Lisko ◽

Adam B. Greenbaum ◽

Jaffar M. Khan ◽

Norihiko Kamioka ◽

Patrick T. Gleason ◽

...

Keyword(s):

Mitral Valve ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Left Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Left Ventricular ◽

Investigational Device Exemption ◽

Transcatheter Mitral Valve Replacement ◽

Patients At Risk ◽

Left Ventricular Outflow

Background: Intentional laceration of the anterior mitral leaflet (LAMPOON) is an effective adjunct to transcatheter mitral valve replacement that prevents left ventricular outflow tract (LVOT) obstruction. To date, LAMPOON has been performed in over 150 patients using a retrograde approach that can be technically challenging. A modified antegrade transseptal technique may simplify the procedure. Methods: Antegrade LAMPOON was developed and tested in nonsurvival pig experiments. Thereafter, antegrade LAMPOON was performed in patients at prohibitive risk of LVOT obstruction. Clinical, procedural, and angiographic details were abstracted from medical records of their index procedure, and were compared with findings in comparable patients at risk of fixed-LVOT obstruction in the LAMPOON investigational device exemption trial. Results: Eight patients at risk of fixed LVOT obstruction underwent antegrade LAMPOON. Leaflet traversal and laceration were technically successful in all. There were no cases of clinically significant LVOT obstruction (mean LVOT gradient at discharge: 5.4±1.4 mm Hg). One patient suffered a ventricular wire perforation, unrelated to the antegrade LAMPOON technique, and did not survive to discharge. At the time of discharge, no patients had an increase of >10 mm Hg in LVOT gradient compared with baseline. Procedure times (from traversal to transcatheter mitral valve replacement) were shorter, compared with the retrograde technique in the LAMPOON investigational device exemption trial (39±09 versus 65±35 minutes). All patients survived (8/8, 100%) the procedure, and 7/8 (88%) survived to 30 days, similar to subjects in the LAMPOON investigational device exemption trial. Conclusions: Antegrade LAMPOON is an effective, reproducible, and simplified strategy to lacerate the anterior leaflet before transcatheter mitral valve replacement. The authors recommend the technique as the new standard for LAMPOON.

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