Author + information
- Received September 28, 2018
- Revision received November 28, 2018
- Accepted December 4, 2018
- Published online January 21, 2019.
- Sung-Han Yoon, MDa,
- Sabine Bleiziffer, MDb,c,
- Azeem Latib, MDd,
- Lena Eschenbach, MDb,c,
- Marco Ancona, MDd,
- Flavien Vincent, MDe,
- Won-Keun Kim, MDf,
- Axel Unbehaum, MDg,
- Masahiko Asami, MDh,
- Abhijeet Dhoble, MDi,
- Miriam Silaschi, MDj,
- Antonio H. Frangieh, MDk,
- Verena Veulemans, MDl,
- Gilbert H.L. Tang, MDm,
- Shingo Kuwata, MDn,
- Rajiv Rampat, MDo,
- Tobias Schmidt, MDp,
- Amisha J. Patel, MDq,
- Pedro Felipe Gomez Nicz, MDr,
- Luis Nombela-Franco, MDs,
- Annapoorna Kini, MDt,
- Mitsunobu Kitamura, MDp,
- Rahul Sharma, MDa,
- Tarun Chakravarty, MDa,
- David Hildick-Smith, MDo,
- Martin Arnold, MDu,
- Fabio Sandoli de Brito Jr., MDv,
- Christoph Jensen, MDw,
- Christian Jung, MDl,
- Hasan Jilaihawi, MDx,
- Richard W. Smalling, MDi,
- Francesco Maisano, MDn,
- Albert Markus Kasel, MDk,
- Hendrik Treede, MDj,
- Joerg Kempfert, MDg,
- Thomas Pilgrim, MDh,
- Saibal Kar, MDa,
- Vinayak Bapat, MDq,
- Brian K. Whisenant, MDy,
- Eric Van Belle, MDe,
- Victoria Delgado, MDz,
- Thomas Modine, MDe,
- Jeroen J. Bax, MDz and
- Raj R. Makkar, MDa,∗ ()
- aDepartment of Interventional Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
- bDepartment of Cardiovascular Surgery, German Heart Center Munich, Technische Universität, Munich, Germany
- cInsure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- dInterventional Cardiology Unit, EMO-GVM Centro Cuore Columbus & San Raffaele Scientific Institute, Milan, Italy San Raffaele Hospital, Milan, Italy
- eDepartment of Cardiology/Cardiac Surgery, CHU Lille, Inserm, U1011, University of Lille, Lille, France
- fKerckhoff Heart and Thorax Center, Department of Cardiology/Cardiac Surgery, Bad Nauheim, Germany
- gDepartment of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
- hDepartment of Cardiology, Bern University Hospital, Bern, Switzerland
- iDepartment of Cardiology, University of Texas Health Science Center, Houston, Texas
- jDepartment of Cardiac Surgery, University of Halle, Halle, Germany
- kDeutsches Herzzentrum München, Technische Universität München, Munich, Germany
- lDivision of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Dusseldorf, Dusseldorf, Germany
- mDepartment of Cardiovascular Surgery, Mount Sinai Health System, New York, New York
- nUniversity Heart Center, University Hospital Zurich, Zurich, Switzerland
- oSussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
- pDepartment of Cardiology, Asklepios Klink St. Georg, Hamburg, Germany
- qColumbia University Medical Center/New York Presbyterian Hospital, New York, New York
- rDepartment of Cardiology, Hospital Sao Camilo, Sao Paulo, Brazil
- sDivision of Cardiology, Hospital Clinicio San Carlos, Madrid, Spain
- tDivision of Cardiology, Mount Sinai Medical Center, New York, New York
- uDepartment of Cardiology, University Hospital Erlangen, Erlangen, Germany
- vHeart Institute of University of Sao Paulo Medical School, Sao Paulo, Brazil
- wContilia Heart and Vascular Centre, Elisabeth Krankenhaus Essen, Essen, Germany
- xDepartment of Cardiology and Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York
- yDivision of Cardiovascular Diseases, Intermountain Heart Institute, Salt Lake City, Utah
- zDepartment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- ↵∗Address for correspondence:
Dr. Raj Makkar, Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, California 90048.
Objectives The aim of this study was to evaluate the predictors of left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR).
Background LVOT obstruction is a major concern with TMVR, but limited data exist regarding its predictors and impact on outcomes.
Methods Patients with pre-procedural multidetector row computed tomography (MDCT) undergoing TMVR for failed mitral bioprosthetic valves (valve-in-valve), annuloplasty rings (valve-in-ring), and mitral annular calcification (valve-in-MAC) were included in this study. Echocardiographic and procedural characteristics were recorded, and comprehensive assessment with MDCT was performed to identify the predictors of LVOT obstruction (defined as an increment of mean LVOT gradient ≥10 mm Hg from baseline). The new LVOT (neo-LVOT) area left after TMVR was estimated by embedding a virtual valve into the mitral annulus on MDCT, simulating the procedure.
Results Among 194 patients with pre-procedural MDCT undergoing TMVR (valve-in-valve, 107 patients; valve-in-ring, 50 patients; valve-in-MAC, 37 patients), LVOT obstruction was observed in 26 patients (13.4%), with a higher rate after valve-in-MAC than valve-in-ring and valve-in-valve (54.1% vs. 8.0% vs. 1.9%; p < 0.001). Patients with LVOT obstruction had significantly higher procedural mortality compared with those without LVOT obstruction (34.6% vs. 2.4%; p < 0.001). Receiver-operating characteristic curve analysis showed that an estimated neo-LVOT area ≤1.7 cm2 predicted LVOT obstruction with sensitivity of 96.2% and specificity of 92.3%.
Conclusions LVOT obstruction after TMVR was associated with higher procedural mortality. A small estimated neo-LVOT area was significantly associated with LVOT obstruction after TMVR and may help identify patients at high risk for LVOT obstruction.
- annuloplasty ring
- degenerated bioprosthesis
- left ventricular outflow tract obstruction
- mitral annular calcification
- mitral valve
- transcatheter valve implantation
The Department of Cardiology of the Leiden University Medical Center received unrestricted research grants from Edwards Lifesciences, Biotronik, Medtronic, and Boston Scientific. Dr. Bleiziffer has served as a consultant to Medtronic; has served as a proctor for Medtronic and JenaValve; and has received travel compensation from Edwards Lifesciences, Medtronic, and Johnson & Johnson. Dr. Latib has served on an advisory board for Medtronic; and has served as a consultant for Direct Flow Medical. Dr. Kim has served as a proctor for Symmetis and St. Jude Medical. Dr. Dhoble has served as a proctor for Edwards Lifesciences; and has served as a consultant for St. Jude Medical. Dr. Tang has served as a proctor for Edwards Lifesciences. Dr. Smith has served as a proctor for Medtronic and Boston Scientific. Dr. Arnold has received travel compensation from Edwards Lifesciences; has served as a proctor for Edwards Lifesciences; has served as a proctor and consultant for St. Jude Medical; and has received speaking honoraria from JenaValve. Dr. Jilaihawi has served as a consultant for Edwards Lifesciences, St. Jude Medical, and Venus Medtech. Dr. Smalling has received consulting fees and research support from St. Jude and Edwards Lifesciences. Dr. Maisano has served as a consultant for Edwards Lifesciences, Medtronic, St. Jude Medical, Abbott Vascular, and Veltech; and has received royalties from Edwards Lifesciences. Dr. Kasel has served as a consultant for Edwards Lifesciences and received research support from Edwards Lifesciences. Dr. Treede has served as a proctor and consultant for Edwards Lifesciences. Dr. Pilgrim has received speaking fees from Biotronik and Medtronic; and has received travel honoraria from Biotronik and Edwards Lifesciences. Dr. Kempfert has served as a proctor for Edwards Lifesciences, Abbott Vascular, Medtronic, and Biotronik. Dr. Kar has served as a consultant for Abbott Vascular and Boston Scientific. Dr. Bapat has served as a consultant for Edwards Lifesciences, Medtronic, Abbott Vascular, Boston Scientific, and 4Tech. Dr. Whisenant has served as a consultant for Edwards Lifesciences and Boston Scientific. Dr. Delgado has received speaking fees from Abbott Vascular. Dr. Modine has served as a consultant for Boston Scientific. Dr. Makkar has received grants from Edwards Lifesciences; and has received personal fees from St. Jude Medical and Medtronic. All other authors have reported that they have no relationship relevant to the contents of this paper to disclose.
- Received September 28, 2018.
- Revision received November 28, 2018.
- Accepted December 4, 2018.
- 2019 American College of Cardiology Foundation
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