Balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction (BATMAN): A novel technique for patients undergoing transcatheter mitral valve replacement

Abstract

Introduction Transcatheter mitral valve replacement (TMVR) is an option for patients at high risk for mitral valve replacement or repair via sternotomy or left thoracotomy approach. TMVR carries up to 22% risk of left ventricular outflow tract (LVOT) obstruction. Severe LVOT obstruction can have devastating hemodynamic and clinical consequences. Hypothesis We previously presented a novel technique to prevent LVOT obstruction during transapical retrograde mitral valve replacement, by penetrating and ballooning the anterior mitral leaflet (AML), resulting in creation of a “hole” and posterior translocation of AML, then deploying the valve. Methods Three patients underwent TMVR at Saint Louis University for severe mitral regurgitation after being deemed too high risk for surgery, and not candidates for a Mitra‐clip procedure. These patients were deemed to be at risk for LVOT obstruction based on the preprocedural evaluation. Via transapical approach, a needle was advanced “through,” perforating the AML and wire was placed in the left atrium. Over the wire, an 20‐mm valvuloplasty balloon was positioned “within” the anterior leaflet and inflated leading to translocation of the AMVL. Then the valve was deployed. Results This novel technique has been performed on three patients at our institution. Sapien S3 transcatheter valves were used in all three patients, with 100% procedural success rate. Intraoperative TEE demonstrated no significant LVOT obstruction, cardiopulmonary bypass time was 42–44 min. Conclusion The balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction technique described here may offer the option of transcatheter mitral valve implantation in patients at high risk of LVOT obstruction. A variation of this technique to allow application in cases with transseptal approach is under investigation.

Hybrid valve-in-valve mitral valve replacement

“…3 Intentional transcatheter laceration of the anterior mitral valve leaflet to prevent LVOTobstruction (LAMPOON) with radiofrequency energy and transapical balloon-assisted translocation of the mitral anterior leaflet (BATMAN) techniques have proven feasible in preventing this problem but have yet to be replicated in larger series. 4,5 The hybrid approach FIGURE 1. Preoperative computed tomography images with a simulated 29 mm valve-in-valve Edwards SAPIEN 3 transcatheter heart valve (Edwards Lifesciences, Irvine, Calif) in the mitral position demonstrating high risk for LVOT obstruction.…”

“… 3 Intentional transcatheter laceration of the anterior mitral valve leaflet to prevent LVOT obstruction (LAMPOON) with radiofrequency energy and transapical balloon-assisted translocation of the mitral anterior leaflet (BATMAN) techniques have proven feasible in preventing this problem but have yet to be replicated in larger series. 4 , 5 The hybrid approach described herein takes advantage of transcatheter valve replacement with short CPB time while allowing for resection of bioprosthetic leaflets to minimize the danger of LVOT obstruction. This technique also obviates the need to resect the ring of an old bioprosthesis, potentially reducing the risk of permanent pacemaker placement or injury to the circumflex artery associated with repeat MVR.…”

Current Devices in Mitral Valve Replacement and Their Potential Complications

“…Moreover, different techniques were described to avoid or to treat LVOT obstruction during TMVR: alcohol septal ablation (37), radiofrequency septal ablation using SCORPION technique (55), laceration of the anterior mitral leaflet (LAMPOON technique) (56,57), and balloon-assisted translocation of the anterior mitral leaflet (BATMAN technique) (58).…”

“…The BATMAN technique mimics the surgical approach called "translocation of the anterior mitral leaflet with chordal preservation, " with a less invasive access (58). It has similar principles to the LAMPOON technique.…”

Commentary: Hybrid valve-in-valve mitral valve replacement: Surgeon's role matters

“…Currently, major catheter-based ViV-TMVR procedures to avoid neo-LVOT obstruction include the transseptal approach with percutaneous laceration of the anterior mitral leaflet (LAMPOON procedure) using a radiofrequency catheter 6 and the transapical approach with balloon-assisted translocation of the anterior mitral leaflet (BATMAN procedure). 7 Although both procedures have emerged as feasible options, about one half of LAMPOON procedures required the prophylactic use of intra-aortic balloon pumping support 6 and all BATMAN procedures required femoro-femoral CPB. 7 Thus, the degree of “minimal invasiveness” of these catheter-based procedures is questionable.…”