Balloon-Assisted Anterior Mitral Leaflet Translocation for Valve-in-MAC Transcatheter Mitral Valve Replacement
Key result
BATMAN-facilitated TMVR achieved 100% technical success in patients with severe native mitral annular calcification, though 30-day all-cause mortality was 36.4%.
Why the study?
Severe mitral annular calcification complicates transcatheter mitral valve replacement by increasing left ventricular outflow tract obstruction risk, and experience with balloon-assisted anterior mitral leaflet translocation for native valve-in-mitral annular calcification remains limited.
Key Points
- To evaluate the feasibility, hemodynamic results, and early clinical outcomes of balloon-assisted translocation of the anterior mitral leaflet during transcatheter mitral valve replacement for native mitral annular calcification.
- Retrospective evaluation of 11 consecutive patients undergoing balloon-assisted leaflet translocation during native valve-in-mitral annular calcification transcatheter replacement between July 24, 2024, and March 12, 2026, at a single center.
- Preprocedural computed tomography assessed anatomical risk (mean mitral annular area 688.5 ± 201.2 mm², mean predicted neo-left ventricular outflow tract area 196.3 ± 88.8 mm²).
- Procedural adjuncts included Shockwave intravascular lithotripsy in 36.4% (4 of 11), cerebral protection in 63.6%, and pre-procedural alcohol septal ablation in 27.3%.
- Technical success reached 100.0% (11 of 11) with zero valve embolization or significant left ventricular outflow tract obstruction; predischarge mean transmitral gradient was 5.4 ± 1.7 mm Hg.
- In-hospital adverse events included paravalvular leak of moderate or greater requiring closure in 27.3% (3 of 11), pericardiocentesis in 18.2%, and major bleeding, stroke, or surgical conversion in 9.1% each.
- At 30-day follow-up, all-cause mortality was 36.4% (4 of 11), cardiac mortality was 18.2% (2 of 11), and rehospitalization occurred in 66.7% (6 of 9).
Study Design
Type
Observational (n=11)
Multicenter
No
Structured PICO
P
Population
11 older adults (mean age 76.5, 73% female) with severe native mitral annular calcification undergoing BATMAN-facilitated TMVR, followed for 30 days.
I
Intervention
Balloon-assisted translocation of the anterior mitral leaflet (BATMAN) facilitated transcatheter mitral valve replacement (TMVR)
O
Outcome
Technical success (successful leaflet modification with BATMAN followed by THV deployment without significant LVOT obstruction, final LVOT mean gradient <10 mm Hg)composite
Limitations
- Single-center experience
- Small sample size
- Retrospective design
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Traditionally, the LAMPOON technique and its various iterations has been used to enable TMVR in patients at high risk of LVOT obstruction; however, this technique has a steep learning curve and is technically more challenging and time-consuming. The findings from this study highlight that BATMAN may be considered as an alternative to LAMPOON associated with excellent efficacy and safety, particularly for ViR and ViV procedures, providing another option for physicians.”
“BATMAN was associated with high technical success, effectiveness in preventing LVOT obstruction, and appeared to be safe in ViR [valve-in-ring] and ViV [valve-in-valve] procedures.”
DEDr. Eric VelazquezChief of Cardiovascular Medicine
“The Yale team's successful execution of this advanced treatment underscores our commitment to pioneering cardiac care as an academic health system.”
Implication
BATMAN-facilitated TMVR for severe native MAC is technically feasible but associated with substantial early mortality, necessitating careful patient selection.
Abstract
BACKGROUND: Severe mitral annular calcification (MAC) complicates transcatheter mitral valve replacement (TMVR) by increasing left ventricular outflow tract (LVOT) obstruction risk. Balloon-assisted translocation of the anterior mitral leaflet (BATMAN) may reduce this risk, but experience with native valve-in-mitral annular calcification (ViMAC) remains limited. CASE SUMMARY: ) underwent BATMAN-facilitated ViMAC TMVR. Technical success was 100%, with no valve embolization or significant LVOT obstruction; paravalvular leak closure was required in 27.3%. Predischarge transmitral gradient was 5.4 ± 1.7 mm Hg; 30-day all-cause and cardiac mortality rates were 36.4% and 18.2%, respectively. DISCUSSION: Published BATMAN reports support feasibility, but ViMAC-specific data are limited. This series addresses high-risk anatomy with few alternatives and substantial early hazard. TAKE-HOME MESSAGES: BATMAN-facilitated ViMAC TMVR appears feasible without technique-related adverse events, but early mortality remains substantial. Use requires multidisciplinary selection and shared decision-making.
Discussion
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Cite This Study
Giacaman et al. (2026) conducted an observational in Severe native mitral annular calcification (ViMAC) (n=11). BATMAN-facilitated TMVR was evaluated on Technical success. BATMAN-facilitated TMVR achieved 100% technical success in patients with severe native mitral annular calcification, though 30-day all-cause mortality was 36.4%.