Alcohol Septal Ablation to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Replacement: First-in-Man Study

JACC Cardiovasc Interv. 2019 Jul 8;12(13):1268-1279. doi: 10.1016/j.jcin.2019.02.034.

Abstract

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.

Keywords: alcohol septal ablation; left ventricular outflow tract obstruction; mitral annular calcification; mitral stenosis; transcatheter mitral valve replacement.

Publication types

  • Multicenter Study

MeSH terms

  • Ablation Techniques* / adverse effects
  • Aged
  • Aged, 80 and over
  • Cardiac Catheterization* / adverse effects
  • Cardiac Catheterization* / instrumentation
  • Ethanol / administration & dosage*
  • Female
  • Heart Valve Diseases / diagnostic imaging
  • Heart Valve Diseases / physiopathology
  • Heart Valve Diseases / surgery*
  • Heart Valve Prosthesis
  • Heart Valve Prosthesis Implantation* / adverse effects
  • Heart Valve Prosthesis Implantation* / instrumentation
  • Hemodynamics
  • Humans
  • Iatrogenic Disease / prevention & control*
  • Male
  • Middle Aged
  • Mitral Valve / diagnostic imaging
  • Mitral Valve / physiopathology
  • Mitral Valve / surgery*
  • Registries
  • Retrospective Studies
  • Risk Factors
  • Treatment Outcome
  • United States
  • Ventricular Outflow Obstruction / diagnostic imaging
  • Ventricular Outflow Obstruction / etiology
  • Ventricular Outflow Obstruction / physiopathology
  • Ventricular Outflow Obstruction / prevention & control*

Substances

  • Ethanol