Sequential Use of Alcohol Septal Ablation and Electrosurgical Leaflet Resection Prior to Transcatheter Mitral Valve Replacement

In patients with increased surgical risk and hemodynamically significant mitral disease, a transcatheter strategy for mitral valve replacement (TMVR) may be suitable; however, is also not without procedure risk. Obstruction of the left ventricular outflow tract (LVOT) is one of the most dreaded complications of TMVR, requiring careful consideration of potential candidates with preprocedural imaging and ex vivo valvular fit simulation as part of risk assessment for postprocedure obstruction. In patients at high risk of LVOT obstruction, early studies have shown that alcohol septal ablation or electrosurgical laceration of the anterior mitral leaflet (LAMPOON) procedure prior to TMVR may mitigate the risk of LVOT obstruction. We describe the recent successful management of a patient with severe mitral valve disease, mitral annular calcification (MAC), and high risk of post-TMVR LVOT obstruction, who underwent a sequential strategy of ASA followed by electrosurgical leaflet resection with the LAMPOON procedure prior to TMVR to successfully prevent LVOT obstruction. To our knowledge, this is the first time this dual strategy has been reported, and it may allow more patients with severe mitral valve disease to undergo TMVR in the future.