Alcohol Septal Ablation to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Replacement: First-in-Man Study
Wang DD, Guerrero M, Eng MH, Eleid MF, Meduri CU, Rajagopal V, Yadav PK, Fifer MA, Palacios IF, Rihal CS, Feldman TE, and O'Neill WW. Alcohol Septal Ablation to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Replacement: First-in-Man Study. JACC: Cardiovascular Interventions 2019; 12(13):1268-1279.
JACC Cardiovasc Interv
Objectives: This study evaluates outcomes of pre-emptive alcohol septal ablation (ASA) to prevent iatrogenic left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR). Background: LVOT obstruction is a life-threatening complication of TMVR. Bail-out ASA has been described as a therapeutic option for patients with outflow obstruction during TMVR, but little is known about pre-emptive ASA. Methods: Multicenter registry of patients with severe mitral valve disease who underwent pre-emptive ASA to mitigate LVOT obstruction risk after TMVR. High risk of LVOT obstruction was predicted in all patients by pre-procedural computed tomographic imaging. Results: Thirty patients (age 76.1 ± 7.7 years; women 76.7%) with severe mitral valve disease underwent pre-emptive ASA to mitigate TMVR-induced LVOT obstruction risk. Twenty patients underwent mitral valve replacement (14 transseptal, 3 transatrial, 1 transapical, 1 transseptal with percutaneous laceration of anterior mitral leaflet, 1 treated with surgical mitral valve replacement). Eight patients experienced clinical improvement post-ASA. Two patients died before TMVR. Median increase in neo-LVOT surface area post-ASA was 111.2 mm2 (interquartile range: 71.4 to 193.1 mm2). Five patients (16.7%) required pacemaker implantation post-ASA. In-hospital and 30-day mortality post-ASA was 6.7% (2/30 patients). After ASA, TMVR was performed successfully in 100% of attempted cases. In-hospital and 30-day mortality post-TMVR was 5.3% (1/19). Mortality of entire cohort was 10% (3/30 patients: 2 post-ASA before TMVR, 1 died 30 days post-TMVR). Conclusions: Pre-emptive ASA is associated with a significant increase in predicted neo-LVOT area before TMVR and may enable safe TMVR in patients usually excluded secondary to prohibitive risk of LVOT obstruction.