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. 2020 Jun;13(6):e008903.
doi: 10.1161/CIRCINTERVENTIONS.119.008903. Epub 2020 Jun 9.

Antegrade Intentional Laceration of the Anterior Mitral Leaflet to Prevent Left Ventricular Outflow Tract Obstruction: A Simplified Technique From Bench to Bedside

John C Lisko #  1 , Adam B Greenbaum #  1 , Jaffar M Khan  2 , Norihiko Kamioka  1 , Patrick T Gleason  1 , Isida Byku  1 , Jose F Condado  1 , Andres Jadue  1 , Gaetano Paone  1 , Kendra J Grubb  1 , Jasleen Tiwana  3 , James M McCabe  3 , Toby Rogers  2 , Robert J Lederman #  2 , Vasilis C Babaliaros #  1
Affiliations

Antegrade Intentional Laceration of the Anterior Mitral Leaflet to Prevent Left Ventricular Outflow Tract Obstruction: A Simplified Technique From Bench to Bedside

John C Lisko et al. Circ Cardiovasc Interv. 2020 Jun.

Abstract

Background: Intentional laceration of the anterior mitral leaflet (LAMPOON) is an effective adjunct to transcatheter mitral valve replacement that prevents left ventricular outflow tract (LVOT) obstruction. To date, LAMPOON has been performed in over 150 patients using a retrograde approach that can be technically challenging. A modified antegrade transseptal technique may simplify the procedure.

Methods: Antegrade LAMPOON was developed and tested in nonsurvival pig experiments. Thereafter, antegrade LAMPOON was performed in patients at prohibitive risk of LVOT obstruction. Clinical, procedural, and angiographic details were abstracted from medical records of their index procedure, and were compared with findings in comparable patients at risk of fixed-LVOT obstruction in the LAMPOON investigational device exemption trial.

Results: Eight patients at risk of fixed LVOT obstruction underwent antegrade LAMPOON. Leaflet traversal and laceration were technically successful in all. There were no cases of clinically significant LVOT obstruction (mean LVOT gradient at discharge: 5.4±1.4 mm Hg). One patient suffered a ventricular wire perforation, unrelated to the antegrade LAMPOON technique, and did not survive to discharge. At the time of discharge, no patients had an increase of >10 mm Hg in LVOT gradient compared with baseline. Procedure times (from traversal to transcatheter mitral valve replacement) were shorter, compared with the retrograde technique in the LAMPOON investigational device exemption trial (39±09 versus 65±35 minutes). All patients survived (8/8, 100%) the procedure, and 7/8 (88%) survived to 30 days, similar to subjects in the LAMPOON investigational device exemption trial.

Conclusions: Antegrade LAMPOON is an effective, reproducible, and simplified strategy to lacerate the anterior leaflet before transcatheter mitral valve replacement. The authors recommend the technique as the new standard for LAMPOON.

Keywords: cardiac catheterization; electrosurgery; heart valve prosthesis implantation; lacerations; mitral valve; tomography, X-ray computed; ventricular outflow obstruction.

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Conflict of interest statement

Disclosures

ABG is a proctor for Edwards Lifesciences, Medtronic, and Abbott Vascular. He has an equity interest in Transmural Systems. His employer has research contracts for clinical investigation of transcatheter aortic, mitral, and tricuspid devices from Edwards Lifesciences, Abbott Vascular, Medtronic, and Boston Scientific.

JMK is a proctor for Edwards Lifesciences and Medtronic.

GP is a consultant and proctor for Edwards Lifesciences.

KG is a speaker, proctor, and principle investigator for Edwards Lifesciences. She is a speaker, proctor, and advisory board member for Boston Scientific. She is a speaker, proctor, principle investigator, advisory board member, and national principle investigator for Medtronic.

JMM has received honoraria from Edwards Lifesciences, Boston Scientific, and Teleflex All other authors report no relevant conflict of interest.

TR is a proctor for Edwards Lifesciences and Medtronic.

JMK, RJL, and TR are co-inventors on patents, assigned to the NIH, on devices for electrosurgical leaflet laceration. RJL’s employer received research support from Edwards Lifesciences for transcatheter modification of the mitral valve.

VCB is a consultant for Edwards Lifesciences and Abbott Vascular, and his employer has research contracts for clinical investigation of transcatheter aortic, mitral, and tricuspid devices from Edwards Lifesciences, Abbott Vascular, Medtronic, and Boston Scientific. He has an equity interest in Transmural Systems.

Figures

Figure 1:
Figure 1:. Preclinical results of antegrade LAMPOON in swine.
Panels A, C: Initial technique causing eccentric laceration; Panels B, D: Refined technique introducing a catheter fulcrum inside the left atrium, creating midline laceration.
Figure 2:
Figure 2:. Key Steps in antegrade LAMPOON
Panel A: Step 1—A veno-arterial rail is created. 1) A guiding catheter is advanced into the aorta. 2) A snare is placed through this catheter. 3) The mitral valve is crossed usinga balloon tip catheter. 4) A 300-cm wire is snared in the aorta. Panel B: Step 2—Through a LV guiding catheter, an 18–30 Snare is positioned in the left ventricle. A guiding catheter is placed through the other deflectable catheter, through which the insulated wire is advanced to A2 scallop, electrified to facilitate traversal, and snared. Panel C: Step 3—The “flying-V” is positioned in the anterior mitral leaflet. Position is confirmed in multiple fluoroscopic planes. Panel D: Step 4—TMVR is performed in the standard fashion. Above, in mitral annular calcification (*).
Figure 3:
Figure 3:. Images from a representative antegrade LAMPOON procedure
Fluoroscopic (right anterior oblique and caudal (A) and left anterior oblique and caudal, B) and 3-Dimensional transesophageal echocardiographic reconstructions (C). Two antegrade transseptal catheters sheaths are positioned across the interatrial septum and mitral valve, each holding one limb of the “Flying-V” laceration guidewire straddling the A2 cusp of the anterior mitral leaflet. D: 3-Dimensional transesophageal echocardiography reconstruction shows the midline laceration of the A2 anterior mitral leaflet immediately following antegrade-LAMPOON
See this image and copyright information in PMC

References

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