How to Do It: Preventing LVOT Obstruction Valve-in-Valve TMVR

This article is part of CTSNet’s Guest Editor Series, 21 Years After First TAVI: Will Pace of Innovations Continue for All Heart Valves? Guest editor Gry Dahle has curated a robust collection of content that shares the knowledge, techniques, and insights of several distinguished experts from around the world. 

LVOT obstruction after TMVI has very poor outcomes and is related to both a fixed obstruction—a narrowed and elongated neo-LVOT caused by the anterior mitral leaflet being pushed toward the inter ventricular septum—and a dynamic obstruction (SAM). Although the second one is more difficult to predict, the first one can be predicted through accurate preprocedural CT planning and sizing. A step-by-step approach is shown in this video.

This video demonstrates valve-in-valve transeptal transcatheter mitral valve implantation (TMVI) in a high-risk patient. The authors show a combination of all the techniques used to prevent the risk of left ventricular outflow tract (LVOT) obstruction: the septal alcohol ablation and the Lampoon technique (tip-to-base approach) with the implantation of a Sentinel device (for cerebral protection) due to the presence of a left atrial thrombus in a patient with hyperthrophic cardiomyopathy and prior aortic and mitral valve replacement.