Why the study?
Left ventricular outflow tract obstruction is a rare, life-threatening complication of transcatheter mitral valve replacement that may still occur during mitral valve-in-valve procedures and precipitate abrupt hemodynamic collapse.
Case Report (n=1)
No
Demonstrates that severe acute LVOTO following mitral valve-in-valve TMVR can involve both structural and dynamic mechanisms, and that combining structural correction with selective septal branch coil embolization can provide effective percutaneous rescue.
Answers are grounded in this paper and cite their sources.
May enable percutaneous rescue in select acute post-TMVR LVOTO cases; leaves open generalizability and requires prospective validation.
BACKGROUND: Left ventricular outflow tract obstruction (LVOTO) is a rare but potentially life-threatening complication of transcatheter mitral valve replacement (TMVR). Mitral valve-in-valve procedures are generally associated with a lower risk of LVOTO because of the predictable geometry provided by the surgical bioprosthesis, yet severe obstruction may still occur and precipitate abrupt hemodynamic collapse. CASE: A 79-year-old woman with a degenerated 27-mm Carpentier-Edwards Perimount mitral bioprosthesis presented with acute decompensated heart failure due to severe bioprosthetic mitral stenosis. Following multidisciplinary Heart Team evaluation, she was considered not a candidate for redo mitral valve surgery and underwent urgent transseptal valve-in-valve TMVR with a 26-mm balloon-expandable SAPIEN valve. INTERVENTION: Immediately after valve deployment, severe LVOTO developed, with an invasive peak-to-peak LV-aortic gradient of 120 mmHg. A mechanism-guided percutaneous rescue strategy was undertaken. Correction of the structural component of obstruction reduced the gradient to 60 mmHg. Persistent obstruction suggested a significant dynamic contribution, prompting selective septal branch coil embolization, which further reduced the gradient to 20 mmHg and resulted in immediate hemodynamic stabilization. CONCLUSION: Severe LVOTO after valve-in-valve TMVR may reflect both structural and dynamic mechanisms. Persistence of significant obstruction after structural correction should prompt consideration of a dynamic component and may guide effective rescue therapy.
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Mangiameli et al. (2026) conducted a case report in Severe acute left ventricular outflow tract obstruction after transseptal mitral valve-in-valve replacement (n=1). Mechanism-guided percutaneous rescue strategy (structural correction followed by selective septal branch coil embolization) was evaluated on Invasive peak-to-peak LV-aortic gradient and hemodynamic stabilization.
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