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Observational Study
. 2021 Mar 8;14(5):541-550.
doi: 10.1016/j.jcin.2020.11.034. Epub 2021 Mar 1.

Tip-to-Base LAMPOON for Transcatheter Mitral Valve Replacement With a Protected Mitral Annulus

John C Lisko  1 , Vasilis C Babaliaros  2 , Jaffar M Khan  3 , Norihiko Kamioka  1 , Patrick T Gleason  1 , Gaetano Paone  1 , Isida Byku  1 , Jasleen Tiwana  3 , James M McCabe  4 , Krishna Cherukuri  5 , Ramzi Khalil  5 , David Lasorda  5 , Sachin S Goel  6 , Neal S Kleiman  6 , Michael J Reardon  6 , David V Daniels  7 , Christian Spies  7 , Paul Mahoney  8 , Brian C Case  9 , Brian K Whisenant  10 , Pradeep K Yadav  11 , Jose F Condado  1 , Rachel Koch  1 , Kendra J Grubb  1 , Christopher G Bruce  3 , Toby Rogers  12 , Robert J Lederman  3 , Adam B Greenbaum  1
Affiliations
Observational Study

Tip-to-Base LAMPOON for Transcatheter Mitral Valve Replacement With a Protected Mitral Annulus

John C Lisko et al. JACC Cardiovasc Interv. .

Erratum in

  • Correction.
    [No authors listed] [No authors listed] JACC Cardiovasc Interv. 2021 Oct 11;14(19):2194. doi: 10.1016/j.jcin.2021.08.016. JACC Cardiovasc Interv. 2021. PMID: 34620401 No abstract available.

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.

Keywords: left ventricular outflow tract obstruction; mitral annuloplasty; mitral regurgitation; mitral stenosis; surgical mitral valve replacement; transcatheter electrosurgery; transcatheter mitral valve replacement.

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Conflict of interest statement

Funding Support and Author Disclosures This work was supported by the Emory Structural Heart and Valve program intramural funds and by National Institutes of Health Grant No. Z01-HL006040. Dr. Lisko’s employer has contracts for BASILICA analysis with Medtronic and Edwards Lifesciences. Dr. Babaliaros has served as a consultant for Edwards Lifesciences and Abbott Vascular; has an employer with research contracts for clinical investigation of transcatheter aortic, mitral, and tricuspid devices from Edwards Lifesciences, Abbott Vascular, Medtronic, and Boston Scientific; and owns equity interest in Transmural Systems. Drs. Khan and Rogers have served as a proctor for Edwards Lifesciences and Medtronic. Drs. Khan, Lederman, and Rogers are co-inventors on patents, assigned to the National Institutes of Health, on devices for electrosurgical leaflet laceration. Dr. Paone has served as a consultant and proctor for Edwards Lifesciences. Dr. McCabe has served as consultant for Edwards Lifesciences, Boston Scientific, and Teleflex. Dr. Grubb has served as a speaker, proctor, and principal investigator for Edwards Lifesciences; served as a speaker, proctor, and advisory board member for Boston Scientific; and served as a speaker, proctor, principal investigator, advisory board member, and national principal investigator for Medtronic. Dr. Lederman has served as the principal investigator on a cooperative research and development agreement between National Institutes of Health and Edwards Lifesciences for transcatheter modification of the mitral valve. Dr. Greenbaum has served as a proctor for Edwards Lifesciences, Medtronic, and Abbott Vascular; owns an equity interest in Transmural Systems; and has an employer with research contracts for clinical investigation of transcatheter aortic, mitral, and tricuspid devices from Edwards Lifesciences, Abbott Vascular, Medtronic, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

FIGURE 1
FIGURE 1. Key Steps in Preventive Tip-to-Base LAMPOON
(A) A transseptal guidewire is snared in the ascending aorta valve and externalized creating a venoarterial rail. (B) The flying-V lacerating system is positioned at the tip of the mitral valve. Note that the aortic guiding catheter is telescoped to the anterior mitral leaflet to minimize the risk of errant laceration. (C) Laceration is performed from the tip to the base of the mitral leaflet. The red lines indicate the electrified lacerating surface. Full laceration is achieved when the flying V contacts the protected mitral annulus. (D) Transcatheter mitral valve replacement is performed in the standard fashion. LAMPOON = intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction.
FIGURE 2
FIGURE 2. Appropriate Guidewire Alignment
The deflectable guiding catheter is used to position the lacerating system (red arrow) on the middle of the mitral leaflet prior to laceration. This is best confirmed in the left anterior oblique and caudal position.
FIGURE 3
FIGURE 3. Key Steps in “Rescue” Tip-to-Base LAMPOON
(A) A balloon-wedge end-hole catheter is advanced through the mitral valve to facilitate guidewire advancement out of the aortic valve without chordal entrapment. (B) A guidewire is snared in the aortic root and externalized to create a venoarterial rail. (C) The flying V is advanced to the tip of the anterior mitral leaflet. Note that the aortic guiding catheter is telescoped into the left ventricular outflow tract to prevent inadvertent laceration of the aortic valve. (D) The flying V is electrified and tension is applied to lacerate the leaflet. The red line indicates the lacerating surface. The green outline represents the guidewire, blue represents the guiding catheters, and red represents the electrified lacerating surface. LAMPOON = intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction.
CENTRAL ILLUSTRATION
CENTRAL ILLUSTRATION. Tip-to-Base LAMPOON Is a Simplified Approach to Lacerate the Anterior Mitral Leaflet
A comparison of LAMPOON techniques. (A) Retrograde LAMPOON. (B) Tip-to-Base LAMPOON. LAMPOON = intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction; MAC = mitral annular calcification; SMVR = surgical mitral valve replacement.
See this image and copyright information in PMC

Comment in

  • The Multiple Faces of LAMPOON.
    Abdel-Wahab M, Holzhey D. Abdel-Wahab M, et al. JACC Cardiovasc Interv. 2021 Mar 8;14(5):551-553. doi: 10.1016/j.jcin.2020.12.031. Epub 2021 Mar 1. JACC Cardiovasc Interv. 2021. PMID: 33663782 No abstract available.

References

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