John C Lisko1, Vasilis C Babaliaros2, Jaffar M Khan3, Norihiko Kamioka1, Patrick T Gleason1, Gaetano Paone1, Isida Byku1, Jasleen Tiwana3, James M McCabe4, Krishna Cherukuri5, Ramzi Khalil5, David Lasorda5, Sachin S Goel6, Neal S Kleiman6, Michael J Reardon6, David V Daniels7, Christian Spies7, Paul Mahoney8, Brian C Case9, Brian K Whisenant10, Pradeep K Yadav11, Jose F Condado1, Rachel Koch1, Kendra J Grubb1, Christopher G Bruce3, Toby Rogers12, Robert J Lederman3, Adam B Greenbaum1. 1. Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA. 2. Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA. Electronic address: vbabali@emory.edu. 3. Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA. 4. Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA. 5. Division of Cardiology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA. 6. Division of Cardiology, Houston Methodist, Houston, Texas, USA. 7. Division of Cardiology, Palo Alto Medical Foundation, San Francisco, California, USA. 8. Division of Cardiology, Sentara Heart Center, Norfolk, Virginia, USA. 9. Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA. 10. Division of Cardiology, Intermountain Healthcare, Murray, Utah, USA. 11. Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA. 12. Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA; Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
Abstract
OBJECTIVES: The purpose of this study was to evaluate tip-to-base intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction (LAMPOON) in patients undergoing transcatheter mitral valve replacement (TMVR) in annuloplasty rings or surgical mitral valves. BACKGROUND: LAMPOON is an effective adjunct to TMVR that prevents left ventricular outflow tract obstruction (LVOTO). Laceration is typically performed from the base to the tip of the anterior mitral leaflet. A modified laceration technique from leaflet tip to base may be effective in patients with a prosthesis that protects the aortomitral curtain. METHODS: This is a multicenter, 21-patient, consecutive retrospective observational cohort. Patients underwent tip-to-base LAMPOON to prevent LVOTO and leaflet overhang, or therapeutically to lacerate a long anterior mitral leaflet risking or causing LVOTO. Outcomes were compared with findings from patients in the LAMPOON investigational device exemption trial with a prior mitral annuloplasty. RESULTS: Twenty-one patients with a annuloplasty or valve prosthesis-protected mitral annulus underwent tip-to-base LAMPOON (19 preventive, 2 rescue). Leaflet laceration was successful in all and successfully prevented or treated LVOTO in all patients. No patients had significant LVOTO upon discharge. There were 2 cases of unintentional aortic valve injury (1 patient underwent emergency transcatheter aortic valve replacement and 1 patient underwent urgent surgical aortic valve replacement). In both cases, the patients had a supra-annular ring annuloplasty, and the retrograde aortic guiding catheter failed to insulate the guidewire lacerating surface from the aortic root. All patients survived to 30 days. Compared with classic retrograde LAMPOON, there was a trend toward shorter procedure time. CONCLUSIONS: Tip-to-base laceration is a simple, effective, and safe LAMPOON variant applicable to patients with an appropriately positioned mitral annular ring or bioprosthetic valve. Operators should take care to insulate the lacerating surface from adjacent structures.
OBJECTIVES: The purpose of this study was to evaluate tip-to-base intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction (LAMPOON) in patients undergoing transcatheter mitral valve replacement (TMVR) in annuloplasty rings or surgical mitral valves. BACKGROUND: LAMPOON is an effective adjunct to TMVR that prevents left ventricular outflow tract obstruction (LVOTO). Laceration is typically performed from the base to the tip of the anterior mitral leaflet. A modified laceration technique from leaflet tip to base may be effective in patients with a prosthesis that protects the aortomitral curtain. METHODS: This is a multicenter, 21-patient, consecutive retrospective observational cohort. Patients underwent tip-to-base LAMPOON to prevent LVOTO and leaflet overhang, or therapeutically to lacerate a long anterior mitral leaflet risking or causing LVOTO. Outcomes were compared with findings from patients in the LAMPOON investigational device exemption trial with a prior mitral annuloplasty. RESULTS: Twenty-one patients with a annuloplasty or valve prosthesis-protected mitral annulus underwent tip-to-base LAMPOON (19 preventive, 2 rescue). Leaflet laceration was successful in all and successfully prevented or treated LVOTO in all patients. No patients had significant LVOTO upon discharge. There were 2 cases of unintentional aortic valve injury (1 patient underwent emergency transcatheter aortic valve replacement and 1 patient underwent urgent surgical aortic valve replacement). In both cases, the patients had a supra-annular ring annuloplasty, and the retrograde aortic guiding catheter failed to insulate the guidewire lacerating surface from the aortic root. All patients survived to 30 days. Compared with classic retrograde LAMPOON, there was a trend toward shorter procedure time. CONCLUSIONS: Tip-to-base laceration is a simple, effective, and safe LAMPOON variant applicable to patients with an appropriately positioned mitral annular ring or bioprosthetic valve. Operators should take care to insulate the lacerating surface from adjacent structures.
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