Author + information
- Received October 23, 2018
- Revision received January 28, 2019
- Accepted February 14, 2019
- Published online July 1, 2019.
- Dee Dee Wang, MDa,∗ (, )
- Mayra Guerrero, MDb,
- Marvin H. Eng, MDa,
- Mackram F. Eleid, MDb,
- Christopher U. Meduri, MDc,
- Vivek Rajagopal, MDc,
- Pradeep K. Yadav, MDd,
- Michael A. Fifer, MDe,
- Igor F. Palacios, MDe,
- Charanjit S. Rihal, MDb,
- Ted E. Feldman, MDf,g and
- William W. O’Neill, MDa
- aCenter for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan
- bDepartment of Cardiovascular Medicine, Mayo Clinic Hospital, Rochester, Minnesota
- cMarcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia
- dPennsylvania State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania
- eStructural Heart Disease, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- fDivision of Cardiology, NorthShore University Health System, Evanston, Illinois
- gEdwards Lifesciences, Irvine, California
- ↵∗Address for correspondence:
Dr. Dee Dee Wang, Center for Structural Heart Disease, Henry Ford Hospital, 2799 West Grand Boulevard, Clara Ford Pavilion, 432, Detroit, Michigan 48202.
Objectives This study evaluates outcomes of pre-emptive alcohol septal ablation (ASA) to prevent iatrogenic left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR).
Background LVOT obstruction is a life-threatening complication of TMVR. Bail-out ASA has been described as a therapeutic option for patients with outflow obstruction during TMVR, but little is known about pre-emptive ASA.
Methods Multicenter registry of patients with severe mitral valve disease who underwent pre-emptive ASA to mitigate LVOT obstruction risk after TMVR. High risk of LVOT obstruction was predicted in all patients by pre-procedural computed tomographic imaging.
Results Thirty patients (age 76.1 ± 7.7 years; women 76.7%) with severe mitral valve disease underwent pre-emptive ASA to mitigate TMVR-induced LVOT obstruction risk. Twenty patients underwent mitral valve replacement (14 transseptal, 3 transatrial, 1 transapical, 1 transseptal with percutaneous laceration of anterior mitral leaflet, 1 treated with surgical mitral valve replacement). Eight patients experienced clinical improvement post-ASA. Two patients died before TMVR. Median increase in neo-LVOT surface area post-ASA was 111.2 mm2 (interquartile range: 71.4 to 193.1 mm2). Five patients (16.7%) required pacemaker implantation post-ASA. In-hospital and 30-day mortality post-ASA was 6.7% (2/30 patients). After ASA, TMVR was performed successfully in 100% of attempted cases. In-hospital and 30-day mortality post-TMVR was 5.3% (1/19). Mortality of entire cohort was 10% (3/30 patients: 2 post-ASA before TMVR, 1 died 30 days post-TMVR).
Conclusions Pre-emptive ASA is associated with a significant increase in predicted neo-LVOT area before TMVR and may enable safe TMVR in patients usually excluded secondary to prohibitive risk of LVOT obstruction.
- alcohol septal ablation
- left ventricular outflow tract obstruction
- mitral annular calcification
- mitral stenosis
- transcatheter mitral valve replacement
Dr. Wang has served as a consultant to Edwards Lifesciences, Boston Scientific, and Materialise; and received research grant support from Boston Scientific. Dr. Guerrero has served as a proctor and consultant for and received research grant support from Edwards Lifesciences. Dr. Eng has served as a proctor to Edwards Lifesciences. Dr. Meduri has served on the Advisory Board for Boston Scientific, Admedus, Cardiovalve, and 4Tech; the Steering Committee for Medtronic Apollo Trial; and is the National PI for REPRISE IV (Boston Scientific) and SCOUT (Mitralign). Dr. Yadav is a proctor for Edwards Lifesciences; and has received research grant support. Dr. Fifer serves on the scientific advisory board of MyoKardia, Inc. Dr. Feldman has served as a consultant and received research grant support from Abbott Vascular, Boston Scientific, and Edwards Lifesciences; and is employed by Edwards Lifesciences. Dr. O’Neill has served as a consultant for Edwards Lifesciences, Medtronic, Boston Scientific, Abbott Vascular, and St. Jude Medical; and serves on the Board of Directors of Neovasc Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 23, 2018.
- Revision received January 28, 2019.
- Accepted February 14, 2019.
- 2019 American College of Cardiology Foundation
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