BATMAN-Assisted Valve-in-Valve TMVR With Planned Hemodynamic Support in Severe Pulmonary Hypertension

Figures

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  Figure 1. Preprocedural Multimodality Risk Assessment for LVOT Obstruction (A) Transthoracic echocardiogram, parasternal long-axis view, demonstrating septal hypertrophy (interventricular septal thickness 1.3 cm) and a small left ventricular cavity contributing to predicted left ventricular outflow tract (LVOT) crowding. (B) Preprocedural computed tomography simulation of a 23-mm SAPIEN 3 Resilia transcatheter heart valve (THV) demonstrating the predicted ventricular skirt-to-septum distance (6.6 mm). (C) Computed tomography–simulated neo-LVOT area of 181.2 mm2 (perimeter 83.5 mm), below the 200 mm2 threshold associated with high risk for LVOT obstruction. (D) Computed tomography assessment of the aortomitral angle (52.8°) and mitral annular area (5.1 cm2). (E) Double-oblique multiplanar reconstruction (MPR) computed tomography confirming annular and skirt dimensions used for valve sizing and neo-LVOT prediction.

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  Figure 2. Invasive Hemodynamics Before and After Balloon-Assisted Translocation of the Mitral Anterior Leaflet–Assisted Valve-in-Valve Transcatheter Mitral Valve Replacement (A) Preprocedural right heart catheterization tracings demonstrating severe combined postcapillary pulmonary hypertension (right atrium [RA] 20 mm Hg, pulmonary artery [PA] 99/44 mm Hg, mean 65 mm Hg, pulmonary capillary wedge [PCW] pressure 30 mm Hg) and reduced cardiac index (1.9 L/min/m2). (B) Hemodynamic tracings following balloon-assisted translocation of the mitral anterior leaflet–assisted valve-in-valve transcatheter mitral valve replacement, demonstrating a mean transmitral gradient of 1 mm Hg without evidence of left ventricular outflow tract obstruction. Invasive hemodynamics were not separately recorded before and after isolated intra-aortic balloon pump insertion, as the intra-aortic balloon pump was placed as planned prophylactic support rather than for hemodynamic testing. AO = aortic; HR = heart rate; LA = left atrium; LV = left ventricle; NIBP = noninvasive blood pressure; RV = right ventricle; SEP = systolic ejection period.

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  Figure 3. Sequential Steps of Balloon-Assisted Translocation of the Mitral Anterior Leaflet Procedure (A) Following transseptal puncture, a steerable guide catheter is advanced and positioned within the left atrium directed toward the anterior mitral leaflet; sternal wires and the surgical mitral ring are visible. (B) Electrosurgical traversal of the anterior mitral leaflet using an electrified Confianza Pro wire advanced across the leaflet tissue from the left atrium into the left ventricle. (C) Balloon dilation of the anterior mitral leaflet using sequential 8 × 40 mm and 12 × 40 mm balloons, achieving balloon-assisted translocation of the mitral anterior leaflet away from the left ventricular outflow tract. (D) The 12 × 40 mm balloon retracted to the interatrial septum and inflated to perform atrial septostomy, dilating the transseptal tract in preparation for the valve delivery system. (E) Completed balloon atrial septostomy with resolution of the balloon waist, confirming free device movement across the septum before advancement of the valve delivery system.

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  Figure 4. Transesophageal Echocardiographic Guidance During Balloon-Assisted Translocation of the Mitral Anterior Leaflet Traversal (A) Two-dimensional transesophageal echocardiography demonstrating the Confianza Pro wire (arrows) traversing the anterior mitral leaflet, with the aortic valve immediately anterior, confirming intraleaflet wire position before and during balloon dilation. (B) Color Doppler transesophageal echocardiography across the leaflet puncture site during electrosurgical traversal and balloon dilation.

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  Figure 5. Transcatheter Valve Deployment and Device Closure (A) A 23-mm SAPIEN 3 Resilia transcatheter heart valve advanced transseptally and positioned within the frame of the degenerated surgical bioprosthesis under fluoroscopic and transesophageal echocardiographic guidance. (B) Controlled balloon inflation and full deployment of the SAPIEN 3 Resilia valve, securing stable positioning within the native surgical structure. (C) The 30-mm GORE Septal Occluder fully expanded and deployed across the iatrogenic atrial septal defect, with the delivery cable still attached to verify seating. (D) Final cardiac fluoroscopic view confirming the successful dual-device result with both the transcatheter mitral valve and the fully released septal occluder in place. (E) Retraction and recapture of the cerebral embolic protection device filter system into its delivery sheath from the supra-aortic vessels at the conclusion of the procedure.

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  Figure 6. Post–Transcatheter Mitral Valve Replacement Transesophageal Echocardiographic Assessment of the Neo–Left Ventricular Outflow Tract (A) Two-dimensional and color Doppler imaging of the transcatheter valve and adjacent left ventricular outflow tract confirming unobstructed flow. (B) Measurement of the residual neo–left ventricular outflow tract dimension. (C) Three-dimensional en face reconstruction from the left ventricular aspect confirming a widely patent left ventricular outflow tract around the seated transcatheter valve.

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  Visual Summary. Integrated Structural and Hemodynamic Strategy for High-Risk Valve-in-Valve TMVR Preprocedural computed tomography identified a high risk for LVOT obstruction (predicted neo-LVOT area 181 mm2) in a patient with severe pulmonary hypertension. BATMAN followed by valve-in-valve TMVR, supported with prophylactic IABP, resulted in successful mitral valve replacement without LVOT obstruction and complete elimination of mitral regurgitation. Abbreviations are defined in figure.