Valve-in-Valve for Failing Mitral Bioprosthesis With Tip-to-Base LAMPOON to Prevent Left Ventricular Outflow Tract Obstruction

Transcatheter mitral valve replacement (TMVR) is a new approach for treating failed bioprosthetic valves, annuloplasty repairs, and mitral annular calcification. Computed tomography is the key in procedure planning and guiding to identify patients at high risk of anatomic complications, in particular, for left ventricular outflow tract (LVOT) obstruction. There are several methods to reduce the risk of LVOT obstruction. A simple option is preemptive alcohol septal ablation, but this needs to be done prior to the TMVR procedure. Intentional laceration of the anterior mitral leaflet to prevent LVOT obstruction (LAMPOON), a transcatheter electrosurgical technique to split the anterior mitral valve leaflet immediately prior to TMVR, can be done anterograde or retrograde but requires leaflet traversal, which is technically challenging. In this article, we describe a case of valve-in-valve TMVR in a patient with high risk for LVOT obstruction and a novel simple technique-tip-to-base LAMPOON.