Kissing balloon technique to secure the neo-left ventricular outflow tract in transcatheter mitral valve implantation

Kissing balloon technique to secure the neo-left ventricular outflow tract in transcatheter... 2220 Cardiovascular flashlight doi:10.1093/eurheartj/ehy112 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 6 March 2018 .................................................................................................................................................... Kissing balloon technique to secure the neo-left ventricular outflow tract in transcatheter mitral valve implantation Zouhair Rahhab, Ben Ren, Peter P.T. de Jaegere, and Nicolas M.D.A. Van Mieghem* Department of Interventional Cardiology, Thoraxcenter, Erasmus MC, Room Bd 171, ’s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands * Corresponding author. Tel: 131107035260, Fax: 131104369154, Email: n.vanmieghem@erasmusmc.nl 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 symp- tomatic 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 bal- loon in the left ventricle (white arrow¼ the balloon; *anterior mitral valve leaflet) (Panel E) perfect positioning of the balloon in the LVOT (white arrow¼ 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). AMVL: anterior mitral valve leaflet; LA: left atrium; LV: left ventricle; PMVL: posterior mitral valve leaflet. V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/23/2220/4922636 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

Kissing balloon technique to secure the neo-left ventricular outflow tract in transcatheter mitral valve implantation

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Oxford University Press
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
ISSN
0195-668X
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1522-9645
D.O.I.
10.1093/eurheartj/ehy112
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Abstract

2220 Cardiovascular flashlight doi:10.1093/eurheartj/ehy112 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 6 March 2018 .................................................................................................................................................... Kissing balloon technique to secure the neo-left ventricular outflow tract in transcatheter mitral valve implantation Zouhair Rahhab, Ben Ren, Peter P.T. de Jaegere, and Nicolas M.D.A. Van Mieghem* Department of Interventional Cardiology, Thoraxcenter, Erasmus MC, Room Bd 171, ’s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands * Corresponding author. Tel: 131107035260, Fax: 131104369154, Email: n.vanmieghem@erasmusmc.nl 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 symp- tomatic 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 bal- loon in the left ventricle (white arrow¼ the balloon; *anterior mitral valve leaflet) (Panel E) perfect positioning of the balloon in the LVOT (white arrow¼ 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). AMVL: anterior mitral valve leaflet; LA: left atrium; LV: left ventricle; PMVL: posterior mitral valve leaflet. V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/23/2220/4922636 by Ed 'DeepDyve' Gillespie user on 21 June 2018

Journal

European Heart JournalOxford University Press

Published: Mar 6, 2018

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