Predicting LVOT Obstruction in Transcatheter Mitral Valve Implantation

Blanke, Philipp; Naoum, Christopher; Dvir, Danny; Bapat, Vinayak; Ong, Kevin; Muller, David A.; Cheung, Anson; Ye, Jian; Min, James K.; Piazza, Nicolò; Thériault-Lauzier, Pascal; Webb, John G.; Leipsic, Jonathon

doi:10.1016/j.jcmg.2016.01.005

Cited by 230 publications

(144 citation statements)

References 2 publications

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“…Imaging may predict risk for LVOT obstruction (5,6,9) but their sensitivity and specificity remain uncertain. Nevertheless, it is clear that many patients are excluded from clinical and investigational transcatheter mitral valve therapy out of concern for iatrogenic LVOT obstruction.…”

Section: Discussionmentioning

confidence: 99%

“…These transcatheter mitral stent valves may cause acute left ventricular outflow tract (LVOT) obstruction by displacing the anterior mitral valve leaflet toward the septum. Formal criteria have not been established, but as in surgery (3,4), contributors to LVOT obstruction include angulated mitral and aortic annular planes, long or redundant anterior mitral leaflets, small ventricles, bulging septa, and narrow leaflet-to-septum distance (5–7). Preparatory or bailout transcoronary alcohol septal ablation can debulk the septum (8,9) but risks important myocardial and conduction system injury.…”

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confidence: 99%

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Intentional Laceration of the Anterior Mitral Valve Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Replacement

Khan

Rogers

Schenke

et al. 2016

JACC: Cardiovascular Interventions

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OBJECTIVES The authors propose a novel transcatheter transection of the anterior mitral leaflet to prevent iatrogenic left ventricular outflow tract (LVOT) obstruction during transcatheter mitral valve replacement (TMVR). BACKGROUND LVOT obstruction is a life-threatening complication of TMVR caused by septal displacement of the anterior mitral leaflet. METHODS In vivo procedures in swine were guided by biplane x-ray fluoroscopy and intracardiac echocardiography. Retrograde transaortic 6-F guiding catheters straddled the anterior mitral leaflet. A stiff 0.014-inch guidewire with polymer jacket insulation was electrified and advanced from the LVOT, through the A2 leaflet base, into the left atrium. The wire was snared and externalized, forming a loop that was energized and withdrawn to lacerate the anterior mitral leaflet. RESULTS The anterior mitral leaflet was successfully lacerated in 7 live and 1 post-mortem swine under heparinization. Lacerations extended to 89 ± 19% of leaflet length and were located within 0.5 ± 0.4 mm of leaflet centerline. The chordae were preserved and retracted the leaflet halves away from the LVOT. LVOT narrowing after benchtop TMVR was significantly reduced with intentional laceration of the anterior mitral leaflet to prevent LVOT obstruction than without (65 ± 10% vs. 31 ± 18% of pre-implantation diameter, p < 0.01). The technique caused mean blood pressure to fall (from 54 ± 6 mm Hg to 30 ± 4 mm Hg, p < 0.01), but blood pressure remained steady until planned euthanasia. No collateral tissue injury was identified on necropsy. CONCLUSIONS Using simple catheter techniques, the anterior mitral valve leaflet was transected. Cautiously applied in patients, this strategy can prevent anterior mitral leaflet displacement and LVOT obstruction caused by TMVR.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Intentional Laceration of the Anterior Mitral Valve Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Replacement

Khan

Rogers

Schenke

et al. 2016

JACC: Cardiovascular Interventions

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“…the angle between the mitral annulus trajectory line and the LVOT long axis, which is directly related to the risk of TMVR-related LVOT obstruction) can be readily measured on 3-chamber MPR views (Fig. 12), and the neo-LVOT geometry after TMVR can be predicted on a patient- and device-specific basis by simulating device deployment via stereolithographic file integration [12,26,28]. Dedicated software plugins also allow prediction of the best fluoroscopic angulation for device placement based on preprocedural MDCT data [12,29].…”

Section: Mdct Findings - What the Radiologist And Interventional Cardmentioning

confidence: 99%

Preprocedural planning of transcatheter mitral valve interventions by multidetector CT: What the radiologist needs to know

Faggioni

Gabelloni

Accogli

et al. 2018

European Journal of Radiology Open

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Mitral regurgitation is the most common valve disorder in the Western world, and although surgery is the established therapeutic gold standard, percutaneous transcatheter mitral interventions are gaining acceptance in selected patients who are inoperable or at an exceedingly high surgical risk. For such patients, multidetector computed tomography (MDCT) can provide a wealth of valuable morphological and functional information in the preoperative setting. Our aim is to give an overview of the MDCT image acquisition protocols, post-processing techniques, and imaging findings with which radiologists should be familiar to convey all relevant information to the Heart Team for successful treatment planning.

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“…With the current knowledge about TMVIs, the main issues needing to be addressed are [18,19]: (i) length of anterior mitral leaflet, (ii) aorto-mitral annular plane angle, (iii) implantation depth in the ventricle, (iv) extent of septal bulge and myocardial hypertrophy and (v) type of valve to be selected. In patients with small ventricular cavities (e.g.…”

Section: Preoperative Anatomical Considerations To Avoid Left Ventricmentioning

confidence: 99%

Single centre experience with transapical transcatheter mitral valve implantation†

Dahle

Rein

Fiane

2017

Interactive CardioVascular and Thoracic Surgery

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OBJECTIVES: A transcatheter heart valve technique can be used in failed mitral valve repairs with annuloplasty rings, deterioriated bioprostheses and in mitral annular calcification, all serving as 'docking stations' for balloon-expandable valves. Specially designed transcatheter mitral valve platforms are used in ongoing studies for native mitral valve regurgitation. We present our single centre experience with transcatheter mitral valve implantation-transapical approach procedures in eleven patients. METHODS:Eleven patients were treated between 2011 and 2016. They had severe mitral regurgitation due to either failed repair annuloplasty rings (N = 6), failed bioprostheses (N = 2) or in the native valve (N = 3), all at high risk for open mitral valve surgery. Three different types of transcatheter valves were used: (1) the SAPIEN XT/SAPIEN 3, (2) the Lotus valve and (3) a Tendyne transcatheter mitral valve. Computed tomography reconstruction, echocardiography, 3D printing and bench tests were done in the preoperative evaluation and procedural planning. Transapical approach access was performed via a left minithoracotomy. RESULTS: Implantation success was 100% with no left ventricular outflow tract obstruction. Good haemodynamics and improved New YorkHeart Association class were demonstrated in all patients. One patient died before 30 days due to sepsis. One patient had a valve thrombosis when switching from Coumadin to new oral anticoagulant and had a second valve implanted into the first one as a 'valve-in-valve' procedure. CONCLUSIONS:The transapical approach is a safe and straight forward procedure for accessing the mitral valve. 'Transcatheter aortic valve implantation' prostheses may be used in redo surgery due to an already sufficient 'docking station'. These specially designed new prostheses may be beneficial for addressing mitral valve regurgitation, but are still under evaluation. Anticoagulation is mandatory.

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Predicting LVOT Obstruction in Transcatheter Mitral Valve Implantation

Cited by 230 publications

References 2 publications

Intentional Laceration of the Anterior Mitral Valve Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Replacement

Intentional Laceration of the Anterior Mitral Valve Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Replacement

Preprocedural planning of transcatheter mitral valve interventions by multidetector CT: What the radiologist needs to know

Single centre experience with transapical transcatheter mitral valve implantation†

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