Intentional Percutaneous Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction During Transcatheter Mitral Valve Replacement

First-in-Human Experience

Vasilis C. Babaliaros, Adam B. Greenbaum, Jaffar M. Khan, Toby Rogers, Dee Dee Wang, Marvin H. Eng, William W. O'Neill, Gaetano Paone, Vinod H. Thourani, Stamatios Lerakis, Dennis W. Kim, Marcus Y. Chen, Robert J. Lederman

Research output: Contribution to journalArticle

52 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)798-809
Number of pages12
JournalJACC: Cardiovascular Interventions
Volume10
Issue number8
DOIs
StatePublished - Apr 24 2017
Externally publishedYes

Fingerprint

Lacerations
Mitral Valve
Ventricular Outflow Obstruction
Heart Valves
Catheters
Tomography
Pectinidae
Heart Atria
varespladib methyl
Surgical Instruments
Echocardiography

Keywords

  • left ventricular outflow tract obstruction
  • mitral valve
  • structural heart disease
  • transcatheter mitral valve replacement
  • valvular heart disease

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Intentional Percutaneous Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction During Transcatheter Mitral Valve Replacement : First-in-Human Experience. / Babaliaros, Vasilis C.; Greenbaum, Adam B.; Khan, Jaffar M.; Rogers, Toby; Wang, Dee Dee; Eng, Marvin H.; O'Neill, William W.; Paone, Gaetano; Thourani, Vinod H.; Lerakis, Stamatios; Kim, Dennis W.; Chen, Marcus Y.; Lederman, Robert J.

In: JACC: Cardiovascular Interventions, Vol. 10, No. 8, 24.04.2017, p. 798-809.

Research output: Contribution to journalArticle

Babaliaros, VC, Greenbaum, AB, Khan, JM, Rogers, T, Wang, DD, Eng, MH, O'Neill, WW, Paone, G, Thourani, VH, Lerakis, S, Kim, DW, Chen, MY & Lederman, RJ 2017, 'Intentional Percutaneous Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction During Transcatheter Mitral Valve Replacement: First-in-Human Experience', JACC: Cardiovascular Interventions, vol. 10, no. 8, pp. 798-809. https://doi.org/10.1016/j.jcin.2017.01.035
Babaliaros, Vasilis C. ; Greenbaum, Adam B. ; Khan, Jaffar M. ; Rogers, Toby ; Wang, Dee Dee ; Eng, Marvin H. ; O'Neill, William W. ; Paone, Gaetano ; Thourani, Vinod H. ; Lerakis, Stamatios ; Kim, Dennis W. ; Chen, Marcus Y. ; Lederman, Robert J. / Intentional Percutaneous Laceration of the Anterior Mitral Leaflet to Prevent Outflow Obstruction During Transcatheter Mitral Valve Replacement : First-in-Human Experience. In: JACC: Cardiovascular Interventions. 2017 ; Vol. 10, No. 8. pp. 798-809.
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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.",
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T2 - First-in-Human Experience

AU - Babaliaros, Vasilis C.

AU - Greenbaum, Adam B.

AU - Khan, Jaffar M.

AU - Rogers, Toby

AU - Wang, Dee Dee

AU - Eng, Marvin H.

AU - O'Neill, William W.

AU - Paone, Gaetano

AU - Thourani, Vinod H.

AU - Lerakis, Stamatios

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N2 - 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.

AB - 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.

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KW - structural heart disease

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KW - valvular heart disease

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