Key result
Kissing balloon technique during TMVI prevents neo-LVOT obstruction with a post-procedure gradient of 5 mmHg.
Why the study?
In a patient referred for TMVI due to excessive mitral annular calcification and symptomatic severe mitral stenosis, pre-procedural imaging and simulations predicted neo-LVOT obstruction, motivating a kissing balloon technique to orientate the transcatheter valve and secure a properly sized neo-LVOT.
Does the kissing balloon technique prevent neo-left ventricular outflow tract obstruction in a patient with severe mitral annular calcification undergoing transcatheter mitral valve implantation?
Case Report (n=1)
Does the kissing balloon technique prevent neo-left ventricular outflow tract obstruction in a patient with severe mitral annular calcification undergoing transcatheter mitral valve implantation?
Answers are grounded in this paper and cite their sources.
Simultaneous LVOT balloon inflation (kissing balloon technique) during transcatheter mitral valve implantation can guide valve orientation and prevent predicted neo-LVOT obstruction in severe mitral annular calcification.
A 51-year-old male with a past medical history of Hodgkin lymphoma treated with mantle-field radiation and two prior sternotomies for aortic valve disease was referred for transcatheter mitral valve implantation (TMVI) due to excessive mitral annular calcification and symptomatic severe mitral stenosis. Based on 3D–4D multislice computed tomography reconstruction, 3D printing and multiple TMVI simulations predicted neo-left ventricular outflow tract (LVOT) obstruction. Under transoesophageal guidance a 20 mm valvuloplasty balloon was positioned in the LVOT to locate the entrance of the LVOT by fluoroscopy. Kissing balloon technique was subsequently applied by simultaneous inflation of the 20 mm valvuloplasty balloon and a 29 mm SAPIEN3 valve (Edwards Lifesciences, Irvine, CA, USA). The rationale for the LVOT balloon inflation was to identify the landing zone and optimally orientate the transcatheter valve in order to secure a properly sized neo-LVOT. This case illustrates that the kissing balloon technique may guide positioning of transcatheter heart valve and secure patent neo-LVOT in TMVI. (Panel A) Excessive mitral annular calcification on computed tomography (Panel B) simulation of the implantation of a SAPIEN3 29 mm valve predicting paravalvular leakage and LVOT obstruction. (Panel C) Concept of the kissing balloon technique; inflated balloon in the LVOT (red) while deploying the valve in mitral position (yellow) will prevent neo-LVOT obstruction by redirecting the valve. (Panels D–F) A 20 mm valvuloplasty balloon identified the LVOT and guided positioning of SAPIEN3 29 valve; (Panel D) too deep positioning of the balloon in the left ventricle (white arrow = the balloon; *anterior mitral valve leaflet) (Panel E) perfect positioning of the balloon in the LVOT (white arrow = tip of the balloon; *anterior mitral leaflet) (Panel F) guidance of the SAPIEN3 valve in mitral position (Panel G) implantation of the SAPIEN3 valve with inflated balloon in LVOT preventing neo-LVOT obstruction (kissing balloon technique). (Panel H–K) Successful valve implantation with (Panel I) trivial paravalvular leakage and (Panel J) without LVOT obstruction (LVOT outflow max velocity of 1.5 m/s); (Panel K) pre-discharge transthoracic echocardiography colour Doppler showing mitral inflow and mild stenosis (peak V1.8 m/s; mean gradient of 5 mmHg).
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Rahhab et al. (2018) conducted a case report in Excessive mitral annular calcification and symptomatic severe mitral stenosis with predicted neo-LVOT obstruction (n=1). Kissing balloon technique (simultaneous inflation of a 20 mm valvuloplasty balloon in the LVOT and a 29 mm SAPIEN3 valve in the mitral position) was evaluated on Successful transcatheter mitral valve implantation without neo-left ventricular outflow tract (LVOT) obstruction. Kissing balloon technique during TMVI secured a patent neo-LVOT without obstruction and resulted in a mean mitral gradient of 5 mmHg.
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