Author + information
- Received December 23, 2016
- Revision received January 30, 2017
- Accepted January 31, 2017
- Published online April 17, 2017.
- Vasilis C. Babaliaros, MDa,
- Adam B. Greenbaum, MDb,
- Jaffar M. Khan, BMBChc,
- Toby Rogers, PhD, BMBChc,
- Dee Dee Wang, MDb,
- Marvin H. Eng, MDb,
- William W. O’Neill, MDb,
- Gaetano Paone, MDb,
- Vinod H. Thourani, MDa,
- Stamatios Lerakis, MDa,
- Dennis W. Kim, MD, PhDa,d,
- Marcus Y. Chen, MDc and
- Robert J. Lederman, MDc,∗ ()
- aStructural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia
- bCenter for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
- cCardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
- dChildren’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
- ↵∗Address for correspondence:
Dr. Robert J. Lederman, Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, Maryland 20892-1538.
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.
- left ventricular outflow tract obstruction
- mitral valve
- structural heart disease
- transcatheter mitral valve replacement
- valvular heart disease
Supported without industry funding by the clinical programs of the Structural Heart and Valve Center, Emory University Hospital; the Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System; and the Division of Intramural Research (Z01-HL006040), National Heart Lung and Blood Institute, National Institutes of Health. Dr. Babaliaros is a consultant for Edwards Lifesciences and Abbott Vascular; and his employer has research contracts from Edwards Lifesciences, Abbott Vascular, Medtronic, St Jude Medical, and Boston Scientific. Dr. Greenbaum is a proctor for Edwards Lifesciences and St Jude Medical. Dr. O’Neill is a consultant for Edwards Lifesciences, Medtronic, Boston Scientific, Abbott Vascular, and St. Jude Medical; and serves on the Board of Directors of Neovasc Inc. Dr. Thourani is a consultant for Edwards Lifesciences. Dr. Lerakis is a consultant for Edwards Lifesciences and Abbott Vascular. Dr. Kim is a consultant for Edwards Lifesciences; and a proctor for B. Braun. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Babaliaros, Greenbaum, and Khan contributed equally to this work.
- Received December 23, 2016.
- Revision received January 30, 2017.
- Accepted January 31, 2017.