Author + information
- Received January 22, 2018
- Revision received April 2, 2018
- Accepted April 5, 2018
- Published online September 3, 2018.
- Jaffar M. Khan, BM BCha,
- Toby Rogers, PhD, BM BCha,
- Vasilis C. Babaliaros, MDb,
- Melissa Fusari, MDd,
- Adam B. Greenbaum, MDc and
- Robert J. Lederman, MDa,∗ ()
- aCardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- bStructural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia
- cCenter for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan
- dEdwards Lifesciences, Irvine, California
- ↵∗Address for correspondence:
Dr. Robert J. Lederman, Cardiovascular 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.
- left ventricular outflow tract obstruction
- mitral annular calcification
- transcatheter mitral valve replacement
- transcoronary alcohol septal ablation
Transcatheter mitral valve replacement (TMVR) is a potential treatment for patients with severe mitral valve disease and high surgical risk (Figures 1, 2, 3, 4, 5, and 6⇓⇓⇓⇓⇓⇓). Pre-procedure computed tomography is mandatory to determine the risk of the following: 1) valve embolization; 2) paravalvular leak; and 3) left ventricular outflow tract (LVOT) obstruction. The neoLVOT area, measured using a computed tomography–simulated valve, predicts LVOT obstruction from TMVR (1). This assumes the anterior leaflet covers any open valve stent cells. Transcatheter laceration of the anterior mitral leaflet to prevent outflow obstruction (LAMPOON [NHLBI DIR LAMPOON Study: Intentional Laceration of the Anterior Mitral Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Implantation]; NCT03015194) (2) or surgical leaflet resection allows blood flow across uncovered stent cells, relieving LVOT obstruction. However, protruding fabric skirts on transcatheter heart valves may still obstruct the LVOT. We call the residual area after TMVR and anterior leaflet resection the “skirt neoLVOT.” Among 40 patients who underwent LAMPOON-TMVR, 3 had LVOT gradients >50 mm Hg post-TMVR and those uniquely had skirt neo-LVOT areas <150 mm2. They required emergency alcohol septal ablation despite anterior leaflet modification. We recommend measuring skirt neoLVOT whenever planning TMVR with anterior mitral leaflet modification, whether surgical or transcatheter. Future study, perhaps with computational fluid dynamics, is warranted to validate our cutoff.
The National Heart, Lung, and Blood Institute has a collaborative research and development agreement with Edwards Lifesciences on transcatheter modification of the mitral valve. Dr. Babaliaros is a consultant for Edwards Lifesciences and for Abbott Vascular; and his employer has research contracts for clinical investigation of transcatheter aortic and mitral devices from Edwards Lifesciences, Abbott Vascular, Medtronic, St. Jude Medical, and Boston Scientific. Dr. Fusari is an employee of Edwards Lifesciences. Dr. Greenbaum is a proctor for Edwards Lifesciences and Abbott St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 22, 2018.
- Revision received April 2, 2018.
- Accepted April 5, 2018.
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- Babaliaros V.C.,
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