Mitral Valve Leaflet Modification

Q: What is the clinical evidence from this study?

Study design: Review. Population: Left ventricular outflow tract obstruction risk in transcatheter mitral valve replacement. Intervention: Mitral leaflet modification (LAMPOON and related techniques).

Q: What does this research mean for the field?

Mitral leaflet modification techniques such as LAMPOON effectively prevent transcatheter mitral valve replacement-induced left ventricular outflow tract obstruction when guided by preprocedural cardiac computed tomography planning. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

James M. McCabe; Robert J. Lederman; David Elison; Greg Condos; Toby Rogers; Amar Krishnaswamy; Frederik Uttenthal; Stephanie Sellers; Prakriti Gaba; J. Rier; Brian K. Whisenant; Paul Mahoney; Jeremiah P. Depta; Mohamed Abdel-Wahab; Pinak B. Shah; Simon Cheung-Chi Lam; Jason Foerst; Isida Byku; Christine J. Chung; Christopher G. Bruce; Marvin H. Eng; Calvin Choi; Roger J. Laham; Paolo Denti; Mayra Guerrero; Ho-On Alston Conrad Chiu; John Saxon; Rajaram Anantharaman; Logan Vincent; Chun‐Ka Wong; Matteo Saccocci; Ander Regueiro; G. Burkhard Mackensen; Ignacio J. Amat‐Santos; Adam B. Greenbaum; Jaffar M. Khan; Vasilis C. Babaliaros; Phillip Freeman

doi:10.1016/j.jcin.2026.04.029

Key Points

To synthesize international operator experience and establish contemporary best-practice guidance for anterior mitral leaflet modification to prevent left ventricular outflow tract obstruction during transcatheter mitral valve replacement.
Convened 30 out of 38 (79%) experienced international mitral leaflet modification operators across 3 continents using a modified-Delphi consensus framework across 3 iterative email rounds.
Evaluated procedural steps, transcatheter electrosurgery principles, postprocedural care, and ECG-gated contrast-enhanced cardiac computed tomography analysis with slice thickness and in-plane resolution ≤1 mm.
Identified computed tomography-derived predicted neoLVOT area <200 mm2 as predictive of important or life-threatening obstruction after replacement, while active patients may require >250 mm2 to avoid functional obstruction.
Established that a skirt-neoLVOT area ≤200 mm2 risks obstruction despite anterior mitral leaflet laceration, warranting consideration of preemptive septal reduction therapy.
Endorsed leaflet modification techniques, including base-to-tip and tip-to-base LAMPOON, to enable blood flow through the open-cell frame of balloon-expandable valves.

Structured PICO

P

Population

State-of-the-art review and consensus-based best-practice guidance formulated from the experience of 30 international expert operators.

I

Intervention

Transcatheter mitral leaflet modification (LAMPOON technique) using transcatheter electrosurgery, with or without preparatory septal reduction therapy.

This document synthesizes international expert experience to provide step-by-step best-practice guidance and consensus position statements on mitigating LVOT obstruction during TMVR via mitral leaflet modification.

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Implication

Guides mitral leaflet modification including LAMPOON to prevent TMVR-related LVOT obstruction; extends expert consensus for high-risk procedural planning.

Abstract

Left ventricular outflow tract (LVOT) obstruction is a potentially lethal complication of transcatheter mitral valve replacement (TMVR). The risk for LVOT obstruction can reliably be identified on preprocedural cardiac computed tomography. Intentional LAMPOON (laceration of the anterior mitral leaflet to prevent LVOT obstruction) and related techniques effectively prevent TMVR-induced LVOT obstruction, thereby expanding the treatable patient population. However, perceived technical complexity, the absence of purpose-built devices, and limited training opportunities have hindered the widespread adoption of mitral leaflet modification. This document synthesizes international experience to provide contemporary best-practice guidance for mitral leaflet modification. This state-of-the-art review details transcatheter electrosurgery principles, computed tomography-based risk analysis and procedural planning, a step-by-step guide to the LAMPOON technique, tips for managing uncommon challenges, and guidance on postprocedural care. These contemporary best practices can help operators achieve or maintain proficiency.

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Cite This Study

McCabe et al. (2026) conducted a review in Left ventricular outflow tract obstruction risk in transcatheter mitral valve replacement. Mitral leaflet modification (LAMPOON and related techniques) was evaluated. Mitral leaflet modification techniques, including intentional LAMPOON, effectively prevent transcatheter mitral valve replacement-induced left ventricular outflow tract obstruction based on expert consensus.

synapsesocial.com/papers/6a3c2375d15afadd906fa330 https://doi.org/10.1016/j.jcin.2026.04.029

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Mitral Valve Leaflet Modification

Key Points

Structured PICO

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Mitral Valve Leaflet Modification

Key Points

Structured PICO

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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