Transcatheter mitral valve replacement (TMVR) is frequently denied because of the risk of left ventricle outflow tract (LVOT) obstruction determined by the anterior mitral leaflet (AML) displacement. Transcatheter, wire-mediated laceration of the AML [laceration of the anterior mitral leaflet to prevent outflow obstruction (LAMPOON)] has been proposed to solve this issue but is time-consuming, complex, and poorly reproducible.1 We developed and tested a transapical, beating heart, direct splitting of the AML. The procedure was performed in an ex vivo beating heart pig model (4Cardio.Lab, Milano, Italy) under real-time transesophageal echocardiographic guidance (iE33, Philips, Eindhoven, the Netherlands) while direct visualization of the valves was enabled by fiberscope imaging (ENF-GP, Olympus Corp., Tokyo, Japan). A 22F Gore DrySeal Sheath was inserted in the left ventricle through the heart apex. Under echo guidance a standard endoscopic scissor (Metzenbaum, Aesculap, Germany) was inserted in the left atrium through the DrySeal allowing precise visualization and alignment with the A2 segment of AML that was cut (Figure 1A and B; see Supplementary material online, Video S1). Transapical beating heart AML endosplitting is a simple alternative to a complex procedure as LAMPOON with no need of an additional access. Moreover, on the basis of the present testing, we believe the endosplitting might be more reproducible to other techniques in terms of length and location of the splitting as confirmed by the specimen findings (Figure 1C and D). Comparative studies will be necessary to confirm this theory. The length of the splitting allows for optimal fitting and sealing of the TMVR in the native MV orifice without LVOT obstruction as we recently demonstrated in human.2
Figure 1.
Confirmation of the anterior mitral leaflet splitting, (A) 2D bi-plane view, (B) 3D transesophageal echocardiography en-face view, (C) on specimen, and (D) on specimen with implanted Tendyne system. AML, anterior mitral leaflet
Supplementary Material
Acknowledgements
We thank Guido Ghelpi and Riccardo Vismara and the rest of the 4CardioLab team for their support during the in-vitro testing.
Consent: No patients were involved in the present case report; all experiments were performed on ex vivo pig hearts. No consents were therefore obtained.
Funding: Research Grant from Abbott, IL USA.
Contributor Information
Laura Besola, Cardiac Surgery Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Via Paradisa, 2, Pisa 56124, Italy.
Alessandro Fiocco, Cardiac Surgery Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Via Paradisa, 2, Pisa 56124, Italy.
Andrea Colli, Cardiac Surgery Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Via Paradisa, 2, Pisa 56124, Italy.
Supplementary material
Supplementary material is available at European Heart Journal—Case Reports.
Data availability
Data are available upon request.
References
- 1. Khan JM, Babaliaros VC, Greenbaum AB, Foerst JR, Yazdani S, McCabe JM, et al. Anterior leaflet laceration to prevent ventricular outflow tract obstruction during transcatheter mitral valve replacement. J Am Coll Cardiol 2019;73:2521–2534. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Charitos EI, Busch N, Renker M, Liakopoulos OJ, Fischer-Rasokat U, Colli A, et al. Direct, transapical, scissors-mediated lampoon: keeping it simple! J Am Coll Cardiol Interv 2023. doi: 10.1016/j.jcin.2022.12.014 [Epublished]. [DOI] [PubMed]
Associated Data
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Supplementary Materials
Data Availability Statement
Data are available upon request.