Figure 1
Steps for virtual valve implantation in valve-in-valve, valve-in-ring, and valve-in-MAC transcatheter mitral valve replacement. Step 1 (left column): The mitral annulus is traced along the failed bioprosthetic valve, surgical ring/band, or MAC, and a virtual valve is implanted at the center where the valve is expected to land. Step 2 (middle column): The left ventricular and mitral annular centerline are compared to evaluate the Emory angle. Lastly, the depth is adjusted. Step 3 (right column): In the case of valve-in-valve TMVR, the depth is adjusted so that the transcatheter heart valve aligns with the post. For valve-in-ring and valve-in-MAC, the depth is adjusted to ensure the external skirt contacts the entire landing zone. MAC: mitral annular calcification; TMVR: transcatheter mitral valve replacement
Figure 2
Assessment of left ventricular outflow tract (LVOT) obstruction risk. Risk of LVOT obstruction is assessed by measuring neo-LVOT (A: long-axis; B: short-axis), skirt neo-LVOT (C: long-axis; D: short-axis), and valve to septum length (optional) (D).
Figure 3
Antegrade laceration of the anterior mitral valve leaflet to prevent left ventricular outflow tract obstruction (LAMPOON). (A) A balloon-wedge end-hole catheter is advanced into the left ventricle (LV) via a transseptal deflectable sheath. A guidewire is then advanced through this into the aorta and ensnared by the multiloop snare, creating a venoarterial rail. This step allows for the stabilization of the LV snare. (B) The electrified guidewire is delivered through a second transseptal deflectable sheath and is used to traverse the anterior mitral leaflet before being ensnared by a multiloop snare positioned in the LV. (C) The flying-V (a kinked and denuded guidewire that allows electrosurgical laceration) is advanced to the anterior mitral leaflet, and a laceration is made. (D) The transcatheter heart valve is then deployed.
Figure 4
Transcatheter septal myotomy by septal scoring along the midline endocardium. (A) A retrograde guide catheter is advanced to engage the basal septum. (B) A stiff guidewire is then advanced through this to traverse the septum until it re-enters the left ventricle (LV). (C) The guidewire is ensnared by a multiloop snare positioned at the left ventricular apex. (D) The flying-V is then advanced and electrified to lacerate the septum.
Table 1
Clinical outcomes of major studies.
| PATIENT NUMBER | TECHNICAL SUCCESS | LVOT OBSTRUCTION | VALVE EMBOLIZATION | NEED FOR SECOND VALVE | CONVERSION TO SURGERY | MORTALITY | STROKE | |
|---|---|---|---|---|---|---|---|---|
| Valve-in-Valve | ||||||||
| Urena 201821 | 34 | 94.1% | 2.9% | 2.9% | 2.9% | 0.0% | 30-day: 5.9%; 1-year: 13.2%; 2-year: 29.4% | 30-day: 5.9% |
| Yoon 201920 | 322 | 94.4% | 2.2% | 0.9% | 2.5% | 0.9% | 30-day: 6.2%; 1-year: 14.0% | 30-day: 2.3% |
| STS/ACC TVT registry (2020)52 | 1,529 | 96.8% | 0.9% | 0.3% | 0% | 0.9% | 30-day: 5.4%; 1-year: 16.7% | 30-day: 1.1%; 1-year: 3.3% |
| VIVID (2021)53 | 857 | 93.5% | 1.8% | 2.4% | 2.8% | - | 30-day: 6.5%; 1-year: 13.8%; 4-year: 37.5% | Procedural: 1.4% |
| MITRAL (2021, 2022)22, 54 | 30 | 100% | 0.0% | 0.0% | 0.0% | 0.0% | 30-day: 3.3%; 1-year: 3.3%; 2-year: 6.7% | 30-day: 3.3%; 1-year: 6.7%; 2-year: 6.7% |
| Valve-in-Ring | ||||||||
| Urena 201821 | 30 | 80.0% | 0.0% | 3.4% | 16.7% | 6.7% | 30-day: 6.7%; 1-year: 12.7%; 2-year: 24.5% | 30-day: 0.0% |
| Yoon 201920 | 141 | 80.9% | 5.0% | 1.4% | 12.1% | 2.8% | 30-day: 9.9%; 1-year: 30.6% | 30-day: 0.0% |
| STS/ACC TVT registry (2020)55 | 123 | 82.9% | 4.9% | 2.4% | 7.3% | 2.4% | 30-day 11.5% | 30-day: 0.0% |
| VIVID (2021)53 | 222 | 82.0% | 5.9% | 7.0% | 10.1% | - | 30-day: 8.6%; 1-year: 23.2%; 4-year: 50.3% | Procedural: 0.5% |
| MITRAL (2021, 2022)19, 54 | 30 | 66.7% | 0.0% | 0.0% | 20% | 0.0% | 30-day: 6.7%; 1-year: 23.3%; 2-year: 50% | 30-day: 3.3%; 1-year: 3.3%; 2-year: 3.6% |
| Valve-in-MAC | ||||||||
| Guerrero 201817 | 116 | 76.7% | 11.2% | 4.3% | 14.7% | 3.4% | 30-day: 25.0%; 1-year: 53.7% | 30-day: 4.3%; 1-year: 6.6% |
| Urena 201821 | 27 | 77.7% | 7.4% | 0.0% | 22.2% | 0.0% | 30-day: 11.1%; 1-year: 41.7%; 2-year: 58.4% | 30-day: 7.4% |
| Yoon 201920 | 58 | 62.1% | 39.7% | 6.9% | 5.2% | 8.6% | 30-day: 34.5%; 1-year: 62.8% | 30-day: 3.9% |
| STS/ACC TVT registry (2020)55 | 100 | 74.0% | 10.0% | 3.0% | 14.0% | 2.0% | 30-day: 21.8% | 30-day: 6.3% |
| MITRAL (2021, 2022)18, 54 | 31 | 74.2% | 9.7% | 0.0% | 3.2% | 0.0% | 30-day: 16.7%; 1-year: 34.5%; 2-year: 39.3% | 30-day: 6.7%; 1-year: 6.9%; 2-year: 10.7% |
[i] ACC: American College of Cardiology; LVOT: left ventricular outflow tract obstruction; MITRAL: mitral implantation of transcatheter valves; STS: Society of Thoracic Surgeons; TVT: transcatheter valve therapy; VIVID: Valve-in-Valve International Data Registry