Transcatheter Mitral Valve Replacement in Failed Bioprosthetic Valve, Ring, and Mitral Annular Calcification Associated Mitral Valve Disease Using Balloon Expandable Transcatheter Heart Valve

Figures

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  Figure 1. Steps for virtual valve implantation in valve-in-valve, valve-in-ring, and valve-in-MAC transcatheter mitral valve replacement. Step 1 (left column): The mitral annulus is traced along the failed bioprosthetic valve, surgical ring/band, or MAC, and a virtual valve is implanted at the center where the valve is expected to land. Step 2 (middle column): The left ventricular and mitral annular centerline are compared to evaluate the Emory angle. Lastly, the depth is adjusted. Step 3 (right column): In the case of valve-in-valve TMVR, the depth is adjusted so that the transcatheter heart valve aligns with the post. For valve-in-ring and valve-in-MAC, the depth is adjusted to ensure the external skirt contacts the entire landing zone. MAC: mitral annular calcification; TMVR: transcatheter mitral valve replacement

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  Figure 2. Assessment of left ventricular outflow tract (LVOT) obstruction risk. Risk of LVOT obstruction is assessed by measuring neo-LVOT (A: long-axis; B: short-axis), skirt neo-LVOT (C: long-axis; D: short-axis), and valve to septum length (optional) (D).

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  Figure 3. Antegrade laceration of the anterior mitral valve leaflet to prevent left ventricular outflow tract obstruction (LAMPOON). (A) A balloon-wedge end-hole catheter is advanced into the left ventricle (LV) via a transseptal deflectable sheath. A guidewire is then advanced through this into the aorta and ensnared by the multiloop snare, creating a venoarterial rail. This step allows for the stabilization of the LV snare. (B) The electrified guidewire is delivered through a second transseptal deflectable sheath and is used to traverse the anterior mitral leaflet before being ensnared by a multiloop snare positioned in the LV. (C) The flying-V (a kinked and denuded guidewire that allows electrosurgical laceration) is advanced to the anterior mitral leaflet, and a laceration is made. (D) The transcatheter heart valve is then deployed.

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  Figure 4. Transcatheter septal myotomy by septal scoring along the midline endocardium. (A) A retrograde guide catheter is advanced to engage the basal septum. (B) A stiff guidewire is then advanced through this to traverse the septum until it re-enters the left ventricle (LV). (C) The guidewire is ensnared by a multiloop snare positioned at the left ventricular apex. (D) The flying-V is then advanced and electrified to lacerate the septum.